Therapist4Chnge

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Hanover Park, Illinois (PRWEB) September 07, 2013

On August 30, 2013, a federal court in New Jersey preliminarily approved an Aetna $120 million UCR (Usual, Customary & Reasonable) class-action settlement with both out-of-network (ONET) providers and patients. The court set a hearing on March 18, 2014 to consider final approval of the settlement. The court appointed attorneys for both patient-subscriber class and provider class. The court set a March 28, 2014 filing deadline for submitting claim forms. ERISAclaim.com’s ONET UCR Claim Specialist Certification Program demystifies this landmark UCR court decision for all out-of-network providers and patients.

Case info: In RE AETNA UCR litigation, civil action NO. 07-3541 (KSH) (CLW), MDL NO. 2020, United States District Court, D. New Jersey, Filed August 30, 2013.

“Nowadays, $120 million settlement seems to be very usual, customary and reasonable (UCR) for out-of-network provider ERISA class actions. This court decision has profound new impact in out-of-network reimbursement litigation because both patients-subscriber class and provider class jointly sued Aetna under ERISA, especially when about 74% of the PPO plans nationwide offer Americans out-of-network coverage in private industry,” says Dr. Jin Zhou, president of ERISAclaim.com, a national expert in ERISA compliance and UCR appeals.

“ERISA class-action lawsuit proves to be the only revenue for the malingering improper UCR denials in US healthcare system, because UCR denials are usual, customary & unreasonable, the No. 2 denials, only secondary to No. 1 denials, overpayment denials and offset,” says Dr. Zhou.

ERISAclaim.com’s ONET UCR ERISA Claim Specialist Certification Programs will systematically demystify this landmark UCR court decision for 2013, especially the essential elements of ERISA claims regulation, successful ERISA administrative appeals as the prerequisites for ERISA judicial reviews on behalf of all similarly situated patients and healthcare providers.

The court preliminarily proved the following settlement terms:

I. “Under the terms, Aetna will pay $60 million to a general settlement fund. [Settlement Agreement at § 9.] Attorneys' fees, administration costs, and service payments to the representative plaintiffs will be paid out of the general settlement fund first. [Id. at §§ 9.2, 11.]3 Upon timely submission of a claim form, members of the two settlement classes will be entitled to a pre-determined reimbursement amount from the remainder of the general fund — up to $40 per year that they are eligible, subject to a pro rata reduction.” according to the court document.
II. “In addition to the $60 million in the general settlement fund, Aetna will pay up to an additional $60 million to two prove-up funds — a subscriber fund ($40 million) and a provider fund ($20 million). [Id. at §§ 10.1, 10.2.]” according to the court document.
III. “Members of each of the two proposed settlement classes may elect to seek compensation either from the general settlement fund without supporting documentation, or from the relevant prove-up fund with supporting documentation establishing timely and valid prove-up claims for reimbursement.” according to the court document.
IV. “Aetna agrees to make available to the settlement administrator certain claim information for the relevant class periods to assist claimants in fulfilling the requirements of the prove-up funds. [See Class Notice, appended as Exh. F to the Settlement Agreement, at Section VI ("Important Information").]” according to the court document.
V. “A claimant who does not qualify for payment in one of the prove-up funds, can apply to the general settlement fund. [Settlement Agreement at §§ 10.1(d), 10.2(d); see also "NOTE" in Section B of the Subscriber and Provider Claim Forms, appended to Settlement Agreement as Exhs. A & B ("Subscriber/Provider Settlement Claims declared ineligible will be considered for eligibility under the General Settlement Fund"); Class Notice, appended as Exh. F to the Settlement Agreement, at Section VI (same).]” according to the court document.
VI. “In exchange, the settlement classes will provide a broad release of claims against Aetna and all other released persons. [Settlement Agreement at § 13.] United and Ingenix are not considered "released persons." [Id. at § 1.41.]” according to the court document.
I'm sure every provider will get about $2.15 but at least it establishes some case law about the practice that I'm sure is widespread.
 

aequitasveritas

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I'm sure every provider will get about $2.15 but at least it establishes some case law about the practice that I'm sure is widespread.
Excellent. Aetna is great to deal with out here in San Diego, but others like UBH and BC need a spanking
 
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Therapist4Chnge

Neuropsych Ninja Faculty
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Oct 7, 2006
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UBH and Medical Mutual are my two least fav. carriers. I actually just opted out of UBH bc of their horrendous reimbursements. Aetna has been okay for me so far...