NOT FOR PUBLICATION WITHOUT THE
APPROVAL OF THE APPELLATE DIVISION
This opinion shall not "constitute precedent or be binding upon any court." Although it is posted on the
internet, this opinion is binding only on the parties in the case and its use in other cases is limited. R. 1:36-3.
SUPERIOR COURT OF NEW JERSEY
APPELLATE DIVISION
DOCKET NO. A-5000-17T2
BAHMAN VOJDANI, D.M.D.,
COMPREHENSIVE DENTAL OF
LINCOLN PARK LLC, GERALD
S. CONVISSAR, D.D.S., P.A.,
JOSEPH W. WOLENSKI, D.M.D.,
P.A., DAN C. PULLEN, D.D.S.,
P.A., and SAMIR RANA, D.M.D.,
Plaintiffs-Appellants,
v.
AETNA LIFE INSURANCE
COMPANY,
Defendant-Respondent.
______________________________
Argued March 12, 2019 – Decided April 29, 2019
Before Judges Yannotti, Rothstadt and Gilson.
On appeal from Superior Court of New Jersey, Law
Division, Somerset County, Docket No. L-0741-17.
Arthur C. Meisel argued the cause for appellants.
Paul D. Kelly argued the cause for respondent (Craig,
Annin & Baxter, LLP, attorneys; Paul D. Kelly, on the
brief).
PER CURIAM
Plaintiffs Dr. Bahman Vojdani, Comprehensive Dental of Lincoln Park,
LLC (CD), Dr. Gerald S. Convissar, Dr. Joseph W. Wolenski, Dr. Dan C. Pullen,
and Dr. Samir Rana appeal from orders entered by the trial court on May 23,
2018, which granted summary judgment in favor of defendant Aetna Life
Insurance Company (Aetna), and denied plaintiffs' motion for leave to file an
amended complaint. We affirm.
We briefly summarize the relevant facts, which are drawn from the record
before the trial court. Plaintiffs are individuals who practice dentistry in New
Jersey. In April 2015, Dr. Vojdani submitted to Aetna a request for benefits in
the amount of $6400 for orthodontic services he provided to A.J.M., who had
been a dependent enrollee under a self-funded, dental-benefits plan.
In April 2015, Aetna made an initial payment to Dr. Vojdani of $800, and
thereafter issued payments totaling $1010.46, for services deemed to have been
provided in April through November 2015. In April 2016, A.J.M. informed
Aetna that she had not seen Dr. Vojdani since June 2015; however, Dr. Vojdani
advised Aetna that he last treated A.J.M. in August 2015. In May 2016, Aetna
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made requests to Dr. Vojdani to recover benefits paid to him totaling $480. Dr.
Vojdani did not respond to Aetna's requests. Thereafter, Aetna recovered $480
it paid on the claims.
Dr. Rana practices dentistry through CD, which submitted claims to Aetna
for services provided to A.A. from May 2016 to June 2016. A.A. had been
enrolled as a dependent beneficiary in a group benefits plan for which Aetna
served as claims administrator. Aetna paid CD $7612.40 on the claims. After
Aetna made these payments, it determined that A.A. was not an eligible enrollee
in the plan as of May 21, 2016. In September 2016, Aetna issued a request to
CD for the return of the payments made for services provided to A.A., but CD
did not respond to the request. Aetna thereafter recovered overpayments totaling
$6084.40.
Dr. Convissar submitted a request for benefits to Aetna in the amount of
$189 for services he provided in December 2015 to K.M., who had been enrolled
in a fully-insured benefits plan. Aetna paid Dr. Convissar $149 on the claim,
but later determined that K.M. was not eligible for benefits when the services
were provided. In February 2017, Aetna requested that Dr. Convissar return the
payment, but received no response. In May 2017, Aetna recovered $149.
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In addition, Dr. Wolenski submitted a claim for benefits to Aetna for
services he provided in November 2015 to A.C., who had been enrolled in a
fully-insured benefits plan. Aetna paid Dr. Wolenski $241 on the claim. After
Aetna made the payment, it determined that A.C. was not eligible for benefits
under the plan when Dr. Wolenski provided the services. In February 2017,
Aetna requested repayment, but Dr. Wolenski did not respond to the request.
Thereafter, Aetna recovered the $241 it paid to Dr. Wolenski.
Dr. Pullen submitted a claim for benefits to Aetna for services he provided
in October 2016 to K.P., who had been a dependent enrollee in an insured group
benefit plan. Aetna paid Dr. Pullen $179 on the claim. After Aetna made the
payment, it learned that K.P. was not eligible for benefits when Dr. Pullen
provided the services. Aetna requested repayment, but Dr. Pullen did not
respond to the request. Aetna thereafter recovered the $179 it paid on the claim.
In June 2017, plaintiffs filed a complaint in which they alleged that Aetna
had wrongfully recovered the payments it made on the submitted claims by
offsetting the amounts paid against future claims submitted by plaintiffs for
services provided to other patients. Plaintiffs sought, among other relief, the
return of the monies recovered on the claims from Dr. Vojdani and CD. They
also sought a declaration that Aetna could not recover the amounts paid on
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claims submitted after coverage for the patients was terminated. Aetna filed its
answer in July 2017, in which it asserted, among other things, that plaintiffs
were not entitled to any relief on their complaint.
In March 2018, following the completion of discovery, the parties filed
motions for summary judgment. Plaintiffs also sought leave to amend their
complaint to add new claims regarding two other dentists. In May 2018, the
judge heard oral argument and thereafter placed his decision on the record.
The judge decided that the material facts were not in dispute, and Aetna
was entitled to judgment as a matter of law. The judge found that Aetna's
reimbursements of its payments were expressly authorized by the Health Claims
Authorization, Processing and Payment Act (HCAPPA), specifically, N.J.S.A.
17B:27-44.2(d), the section of HCAPPA which applies to health insurers. The
judge also decided that plaintiffs would not be permitted to amend their
complaint, because "it would not have any effect on the [c]ourt's [d]ecision."
The judge memorialized his decision in orders dated May 23, 2018, which
granted Aetna's motion for summary judgment, and denied plaintiffs' motions to
amend their complaint and for summary judgment. This appeal followed.
On appeal, plaintiffs argue that: (1) the overpayment recovery provisions
in HCAPPA do not apply to "stand-alone" or "dental-only" benefit plans; (2) the
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overpayment reimbursement provisions in HCAPPA do not apply to benefits
paid to persons who were not covered on the date of service; (3) HCAPPA does
not empower a payer to effect an overpayment reimbursement for covered
services and thereafter inform the covered person that it has no obligation to pay
the provider; (4) Aetna's payments to plaintiffs are not recoverable under the
law of restitution or by self-help recoupment; and (5) if the trial court's orders
on the summary judgment motions are reversed, plaintiffs should be permi tted
to amend their complaint.
When reviewing a trial court's order granting summary judgment, we
apply the same standard that the trial court applies when ruling on a summary
judgment motion. Prudential Prop. & Cas. Ins. Co. v. Boylan, 307 N.J. Super.
162, 167 (App. Div. 1998). Therefore, we must consider whether there are any
genuine issues of material fact and the moving party is entitled to judgment as a
matter of law. R. 4:46-2(c); Brill v. Guardian Life Ins. Co. of Am., 142 N.J.
520, 523 (1995). Here, the material facts are not in dispute.
As noted, plaintiffs argue that the overpayment recovery provisions in
HCAPPA do not authorize Aetna to recover benefits paid on "stand-alone" or
"dental-only" plans. We reject that argument for the reasons stated in our
opinion filed this day in In re Adoption of Amendments to N.J.A.C. 11:22-1.1,
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__ N.J. Super. , (App. Div. 2019). There, we concluded that the paying
entities were authorized by HCAPPA to recover overpayments of benefits paid
under "stand-alone" or "dental-only" plans. Id. at (slip op. at 11).
Plaintiffs further argue that HCAPPA does not permit Aetna to recover
payments made to providers on claims of persons who were not covered on the
dates of service. As we have explained, plaintiffs submitted certain claims to
Aetna for payment, and Aetna initially paid the claims, based on the
understanding that the patients were covered on the dates of services. Later,
Aetna learned that the patients did not have coverage.
Plaintiffs note that HCAPPA requires health insurers to pay certain
submitted claims promptly. Indeed, N.J.S.A. 17B:28-44.2(d)(1) states that a
health insurer must remit payment no later than thirty calendar days after receipt
of the claim or the time established by 42 U.S.C. § 1395(u)(c)(2)(B) for payment
of Medicare claims, whichever is earlier, and no later than forty days after
receipt if the claim is submitted by other than electronic means. In addition, a
health insurer is required to pay the claim if:
(a) the health care provider is eligible at the date of
service;
(b) the person who received the health care service was
covered on the date of service;
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(c) the claim is for a service or supply covered under
the health benefits plan;
(d) the claim is submitted with all the information
requested by the payer on the claim form . . . ; and
(e) the payer has no reason to believe that the claim has
been submitted fraudulently.
[N.J.S.A. 17B:27-44.2(d)(1).]
Plaintiffs contend that because N.J.S.A. 17B:27-44.2(d)(10) states that the
health insurers may seek reimbursement for claims "previously paid pursuant
to" this section, the insurer may only seek reimbursement for the payment of
claims that met the eligibility standards specified in subsection (1). We cannot
agree.
Where, as occurred here, the insurer pays a claim based on the assumption
that the person is covered under a benefits plan, but later learns that the person
did not have coverage on the date of service, the insurer has made an
"overpayment" for purposes of HCAPPA and it is entitled to recover the amount
mistakenly paid. As the trial court aptly observed, this is precisely the situation
the Legislature sought to address in HCAPPA's reimbursement provisions,
particularly since the insurers are required to make eligibility determinations
and pay claims promptly and in doing so, may make mistakes as to coverage.
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Plaintiffs also argued that HCAPPA does not authorize a payer to effect a
reimbursement of an overpayment by withholding a payment due to a provider
for a claim submitted on behalf of a different patient. In support of this
argument, plaintiffs rely upon N.J.S.A. 17B:27-44.2(d)(11)(a)(iii), which states
in part that
[t]he payer may collect the funds for the reimbursement
request by assessing them against payment of any
future claims submitted by the health care provider
after the [forty-fifth] calendar day following the
submission of the reimbursement request to the health
care provider or after the health care provider's rights
to appeal set forth under [N.J.S.A. 17B:27-44.2(e)(1)
and (2)] have been exhausted if the payer submits an
explanation in writing to the provider in sufficient
detail so that the provider can reconcile each covered
person's bill.
Although HCAPPA requires the payer to submit a written explanation to
the provider to allow the provider to "reconcile each covered person's bill," this
does not limit the payer's ability to collect the funds for the reimbursement by
assessing that amount "against payment of any future claims submitted by the
health care provider." As we conclude in In re Amendments to N.J.A.C. 11:22-
1.1, the term "any future claims" includes future claims related to patients other
than the patient for whom the overpayment was made. __ N.J. Super. at __ (slip
op. at 15).
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Plaintiffs further argue that the payments that Aetna made to them are not
recoverable under the law of restitution or by self-help recoupment. In this case,
however, Aetna did not assert claims against plaintiffs for restitution. Aetna
exercised its right under N.J.S.A. 17B:27-44.2(d)(11) for reimbursement of the
overpayments it made to plaintiffs on claims submitted in respect of persons
who were not entitled to coverage.
Furthermore, even if the common law were interpreted and applied as
plaintiffs claim, the reimbursement provisions of HCAPPA abrogate the
common law and provide the payer entities, like Aetna, the right to recoup
overpayments from future claims submitted by the provider, including any
claims for services provided to other patients. See In re Amendments to
N.J.A.C. 11:22-1.1, N.J. Super. at (slip op. at 14-15).
In view of our decision, we need not consider plaintiffs' argument that the
trial court erred by denying their motion to amend the complaint.
Affirmed.
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