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Julie W. Allison PA in partnership with Napoli Shkolnik PLLC filed a lawsuit in the United States District Court for the Western District of Michigan on behalf of four substance abuse treatment centers (Serenity Point Recovery, A Forever Recovery, Behavioral Rehabilitation Services, Best Drug Rehabilitation) against Blue Cross Blue Shield of Michigan (BSBSMI) based upon their failure to properly pay benefits related to substance abuse treatment and other behavioral health disorders for over 4,000 patients. The complaint seeks compensatory damages exceeding $40 million dollars, punitive damages, disgorgement of profits, declaratory and injunctive relief, and attorneys’ fees and costs and other relief.
In early June 2016, A Texas Federal judge issued a landmark decision in favor of a physician-owned hospital and ordered that more than 13 million in unpaid and/or denied claims by Cigna be paid by the insurer. This case, an initial ERISA matter which related to Cigna pursuing an overpayment demand based on alleged fraud in discounted charges and/or failure to collect patient responsibility ultimately led to Cigna bearing the burden of paying claims it failed to properly adjudicate pursuant to ERISA and state law.
This case marks one of the first decisions in which Cigna’s practice of ceasing to process any type of claim, from the date of the issuance of notice of a Special Investigations Unit audit to a provider, has been challenged and successfully litigated against with the court giving no credence to Cigna’s refusal to process claims when argued that evidence of fraud existed. Connecticut General Life Insurance Co. et al. v. Humble Surgical Hospital LLC, No. 4:13-cv-03291, in the U.S. District Court for the Southern District of Texas.
A similar case, based on the same sets of facts and circumstances has recently settled in the U.S. District Court for the Southern District of Florida, TGWC Associates LLC v. CIGNA Health and Life Insurance Company et al, No. 1:15-cv-2479.
Submitted by Anelia Shaheed, Esq.
Part 1 of 2 of a presentation at WCSAD 2016 by Anelia Shaheed, JD. The description of the talk follows: "In depth look at the legal requirements for providers in the mental health and substance abuse field about areas of concern, including legal compliance, risk assessment and management, employment practices, HIPAA, Fraud, False Claims Act, Assignment of Benefits, Audits, Claims Payer Guidelines and More."
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