On Thursday a lawsuit was removed from the Superior Court of New Jersey Law Division, Morris County, to the New Jersey District Court. The case was filed by Cedar Hill Healthcare against Aetna Health Inc. alleging underpayment of claims billed to Aetna under patients’ insurance because of a previous overpayment.
When claims are billed to an insurance company, they are processed under the terms of the patient’s insurance contract and under the terms of any contracts between the insurance company and the medical provider. After the initial processing, insurance companies frequently reserve the right to reconsider the processing under a more intensive review intended to ensure that the processing was performed correctly, the complaint explained.
If a bill was overpaid, the insurance company will seek to recoup payment from the entity that has been overpaid. In seeking the recouped funds, some insurance companies demand a direct payment from the overpaid medical provider. However the medical provider may disagree with the further review and not be willing to tender the payment. This results in some insurance companies seeking to offset the overpaid amount against later billings that are due to the same medical provider.
The plaintiff in the present lawsuit alleged that twelve patients’ bills between 2019-2020 were insured through Aetna and were properly billed and have payment due. Aetna has declined to pay the claims due to an audit showing previous overpayment of the plaintiff’s billings. The plaintiff alleged that Aetna has refused to provide information or appeal of the overpayment amount and has breached the contract by refusing to pay the new billings.
Cedar Hill Healthcare, represented by the law office of Michael Heinemann, filed claims for breach of contract, unjust enrichment, promissory estoppel, and breach of the covenant of good faith and fair dealing.