A $2.7 Million Reversal: Medical Provider Not Paying Back Money, But Receiving $1.5 Million Instead

When one of the nation’s largest health insurers demanded $700,000 from a surgeon as to an alleged series of “overpayments” on prior claims — through an “audit” — the surgeon hired QLG to determine what rights he might have to fight back against what he believed to be an outrageous audit and recoupment demand.

In speaking to Mr. Quadrino, the surgeon realized that the audit was unlawful, even though it appeared to be authorized by the provider agreement he had signed, making him an “in-network” physician. ERISA, however, can wipe out or “pre-empt” portions of such contracts because ERISA provides that it has such power, as a federal law passed by Congress, to control an entire subject area. Armed with that knowledge and represented by Mr. Quadrino and his legal team, the surgeon embarked upon a fight to stop the health insurer from “taking back” or offsetting current claims with the alleged $700,000 in “overpayments”.

When the insurer stopped paying all of the surgeon’s claims, in attempt to put a “squeeze” on him, due to the insurer’s market dominance, the surgeon authorized QLG to commence and pursue a lawsuit in federal court, under ERISA, to stop all of the unlawful tactics and to regain his practice’s cash flow.

In the ensuing legal battle, QLG demonstrated to both the Court and the health insurer that the surgeon had powerful rights under ERISA to obtain legal and equitable relief. After a series of legal maneuvers, the health insurer not only gave up on its $700,000 demand for money back, but it agreed to a settlement in which it made an immediate payment of $2 million to the surgeon.

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