In this matter, the Appellate Division affirmed the Trial Court’s grant of summary judgment to Aetna and denied plaintiff’s motion for leave to file an amended complaint. Plaintiffs claimed that Aetna wrongfully clawed back payments it made on previously submitted claims regarding certain patients by offsetting the amounts against future claims in connection with unrelated patients. With regard to the previously submitted claims, some patients denied that treatments had occurred and other patients were not eligible for benefits. When Aetna requested back the payments it made on those previously submitted claims, the plaintiffs did not respond and, therefore, Aetna recovered the payments from future claims. The plaintiffs sued Aetna arguing that the claw backs were unlawful, but the trial judge found that Aetna’s conduct was expressly authorized by the Health Claims Authorization, Processing and Payment Act (“HCAPPA”). The Appellate Division affirmed the Trial Court’s decision that the requirement that insurers submit a written explanation to the provider so that the provider can “reconcile each covered person’s bill” did not prevent Aetna’s ability to collect the funds against future claims. The Appellate Division also noted that recoupments from "future claims" were not limited to services provided to the patients at issue but can include unrelated payments under HCAPPA.
If you receive a recoupment notice from a payor, you must take immediate action under the relevant statutory framework. Doing nothing is not an option if you want to contest the payor’s determination. As this case demonstrates, if you do not comply with the time frames set forth in HCAPPA in contesting a recoupment, you face the prospect of waiving your rights.