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Cigna On “Prompt Pay Discount” Fraud? “Down From $ 2 Million/Month To $ 200 Thousand/Month” For A Hospital Pay

Hanover Park, IL (PRWEB) January 27, 2012

ERISAclaim.com offers webinars to examine the latest federal court development in an ERISA lawsuit between CIGNA and an out-of-network (OON) hospital, with $ 20 million UCR claim by a hospital and a claim for alleged multi-million dollar prompt pay discount fraud (“fee forgiving”) by Cigna. After the court permitted the hospital’s claim to proceed against Cigna on 03/02/2011, Cigna counter sued the Hospital with a fraud claim against the hospital, under a Cigna antifraud “fee forgiving protocol” to reduce the hospital pay “down from $ 2 million/month to $ 200 thousand/month”. While the Court has yet ruled on the merits of all claims by either party, the court documents show that Cigna has been fully implementing the new “fee forgiving protocol” as an antifraud initiative to deny all out-of-network provider claims, including the alleged “prompt pay discount” fraud.

The Court Case Info: North Cypress Medical Center Operating Co., Ltd. et al v. Cigna Healthcare et al, Case 4:09-cv-02556, Filed: 08/11/2009, United States District Court Southern District of Texas Houston Division.

ERISAclaim.com offers in-depth analysis and timely Court-Watch on this case, as this “ERISA v Discount Fraud” court battle will likely represent the No. 1 health claim denial nationwide for all OON patient and provider claims for 2012, especially in the deductible seasons. It is impossible that every provider can collect every dollar of deductible and co-insurance from every patient in this economy with recession and unemployment rates, while 77% Insured Americans paid for out-of-network coverage in private sectors.

“Cigna will deny ALL OON Claims “in total” with ‘fee forgiving’, while no provider can collect 100% from every patient 100% of the time, therefore this Court case is for every OON patient and provider in USA,” says Dr. Jin Zhou, President of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.

(http://www.cigna.com/health/provider/medical/forms/pdf/Participant_disclosure_form.pdf)

ERISAclaim.com will also discuss compliant proactive ERISA discount practices and ERISA / PPACA appeals for all claims denials and delays.

According to the Court documents, on March 2, 2011, the federal court permitted the hospital’s ERISA lawsuit to proceed.

According to the Court Document, on November 17, 2007, CIGNA filed a counter-lawsuit against the hospital for alleged “prompt pay discount” (“fee forgiving”) fraud, among other things, as a part of its defense, in the Court:

“This action arises from an ongoing scheme by NCMC to defraud CIGNA through a practice known as “fee forgiving.”

“NCMC’s so-called business model wrecks these incentives. Instead of collecting the co-insurance from CIGNA plan members that their plans require them to pay, NCMC waives those payments. NCMC tells CIGNA plan members that it will bill them as if they were seeing an in-network provider, eliminating any financial difference to the member between using NCMC and using another provider in CIGNA’s network. On top of this, NCMC offers these plan members over-the-top “hotel-like accommodations,” unlike those in any traditional hospital, including “all private patient suites with upscale room accommodations, including trim, flat screen televisions, private baths, and wireless internet.”

“Defendants deny the allegations of the third sentence of paragraph 30, except admit that one CIGNA employee wrote an email on or around February 18, 2009 that stated in part “spend at North Cypress Medical Center has come down from $ 2 million/month to $ 200 thousand/month so all of our hard work is paying off and the pressure is being felt by the physicians in the area as well as NCMC, which is a good thing;” Defendants respectfully refer the Court to that email.”

On December 14, 2011, the plaintiff hospital filed a motion to dismiss CIGNA counterclaim, asserting ERISA preemption.

On Jan 11, 2012, the defendant Cigna filed defendants’ response in opposition to plaintiffs’ motion to dismiss defendants’ counterclaims.

According to Cigna Website, Cigna will deny all OON claims “in total” with “fee forgiving”, including “prompt pay discount” (http://www.cigna.com/health/provider/medical/forms/pdf/Participant_disclosure_form.pdf):

“Notice to Participant regarding “fee forgiving” by providers that do not participate in the CIGNA HealthCare network.

Some non-participating providers may offer to waive the amount that you are obligated to pay when you use your out of network benefits by stating that that they will “accept what insurance pays as payment in full.” This conduct may impact your benefit claim. The amount waived may adversely affect the amount of the benefit under your plan. Claims submitted by providers that engage in fee forgiving may be denied in total or you may be required to pay the non-participating provider and then file a claim for reimbursement.

If a non-participating provider offers to waive or forgive any part its charges, please notify the CIGNA HealthCare Special Investigations Hotline at 1.800.667.7145”

To find out more about PPACA Claims and Appeals Compliance Services from ERISAclaim.com:

http://www.erisaclaim.com/products.htm

Located in a Chicago suburb in Illinois, for over 12 years, ERISAclaim.com is the only ERISA & PPACA consulting, publishing and website resource for healthcare providers in the country. ERISAclaim.com offers free webinars, basic and advanced educational seminars and on-site claims specialist certification programs for doctors, hospitals and commercial companies, as well as numerous pending national ERISA class action litigation support. Dr. Jin Zhou is regarded as the industry “Godfather of ERISA claims” for healthcare providers.

For any questions, please contact Dr. Jin Zhou, president of ERISAclaim.com, at 630-808-7237.

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