CLAIMS PROCESSING IN BREACH OF FIDUCIARY DUTY

How can consumers know for sure their claims are paid correctly? How can plan sponsors be sure too? How many take the time and effort necessary for proper plan oversight?

How many self-funded plan sponsors scrutinize their weekly claim check runs? A small 135 life group in South Texas wished they had. Their TPA overpaid claims over a 12 month period by +$27,000. It took almost a year to recoup the overpayments.

Hockenstein_v._CIGNA_HEALTH_AND_LIFE_INSURANCE_COMPANY

”This case exposes many issues but of particular importance are the allegations of CIGNA’s fake discount and fake negotiations. It appears CIGNA just got outed by their own member. This case and allegations should be a wake up call for patients and provide insight into what treating physicians deal with daily.” – Mark Flores, President & Co-Founder of AVYM Corporation

Pleadings Excerpt:

Plaintiff could not possibly know, and indeed, to this day does not know, the basis for Cigna’s claims determinations, or, indeed, whether there is any rhyme or reason at all to Cigna’s landing upon the reimbursement rates of $76.97, or $153.93, or $51.31 – all for the same service, from the same provider, for which Plaintiff paid the same $250.

Cigna’s issuing haphazard and inconsistent claims determinations for the identical Covid-19 tests for Plaintiff and his dependents in September 2021, performed by the same provider, for which Plaintiff paid the same amount, which Plaintiff submitted for reimbursement.

 

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