In the trillion dollar market of overpayment claim industry, this new federal law is undoubtedly critical to all stakeholders in healthcare industry with respect to compliance, business profits and possible bankruptcy for many health care providers
Hanover Park, IL (PRWEB) September 16, 2010
ERISAclaim.com announced new webinar-seminar-certification programs for new federal appeals regulations going into effect on Sep. 23, 2010, especially for all overpayment refund and recoupment disputes. The new federal laws provide unprecedented protections for healthcare providers and consumers with new external appeal protections and new excise tax penalty in $100 per day per patient in case of an external appeal violation by payers. The new federal laws mandate 100% compliance of existing federal law ERISA of 36 years in all 50 states for all types of payers and health plans as well as individual policies.
"The new federal appeals laws with unprecedented protections are extremely timely and important for all health care providers and consumers when overpayment claims from payers are about to outnumber healthcare service claims from healthcare providers", said Dr. Jin Zhou, president of ERISAclaim.com, the only company in the nation offering comprehensive education on new federal appeals laws for healthcare providers and health plans.
"There had been no clear federal law previously for healthcare plans and providers with increasing industry disputes over the true overpayment claims, retrospective benefits denials, provider contract dispute and pure fraud claims", explained by Dr. Zhou. "In the trillion dollar market of overpayment claim industry, this new federal law is undoubtedly critical to all stakeholders in healthcare industry with respect to compliance, business profits and possible bankruptcy for many health care providers".
The new federal regulations for internal and external appeals have been released from White House, IRS, DOL and HHS website:
White House Web Page on Health Reform: http://www.whitehouse.gov/healthreform
DOL Affordable Care Act: http://www.dol.gov/ebsa/healthreform/
HHS Web site on the Affordable Care Act: http://www.healthcare.gov/
IRS Web site on the Affordable Care Act: http://bit.ly/ceIY2O
According to Dr. Zhou, the new federal appeals regulations expand and clarify the definition for adverse benefit determination for post payment review generated overpayment refund disputes and overpayment recoupment or withholding to collect such overpayment.
The preamble of the new regulations released from IRS, DOL and HHS provide in part:
"First, for purposes of these interim final regulations, the definition of an adverse benefit determination is broader than the definition in the DOL claims procedure regulation…… includes …… A denial, reduction, or termination of, or a failure to provide or make a payment (in whole or in part) for a benefit can include both pre-service claims (for example, a claim resulting from the application of any utilization review), as well as post-service claims. Failure to make a payment in whole or in part includes any instance where a plan pays less than the total amount of expenses submitted with regard to a claim, including a denial of part of the claim due to the terms of a plan or health insurance coverage regarding copayments, deductibles, or other cost-sharing requirements".
Interim Final Rules for Group Health Plans and Health Insurance Issuers Relating to Internal Claims and Appeals and External Review Processes Under the Patient Protection and Affordable Care Act; Interim Final Rule [7/23/2010] [page 43332 - 43333, 43354]
As simplified by Dr. Zhou, any overpayment refund for old claims or new overpayment withholding or recoupment from new claims that would result in no payment or a payment less than the amount initially claimed or billed by a healthcare provider will constitute an adverse benefit determination under new federal law, with protections of the internal appeals and new external appeals and possible excise tax penalties in $100 per day per patient in case of an external appeal violation, without having to go to a state or federal court.
For more detailed explanations: http://erisaclaim.com/overpayment_refund.htm
Dr. Zhou further elaborated that federal law ERISA has been around for 36 years, but without education, compliance by health care providers and payers, and without any meaningful enforcement from the federal government. Under new federal reform law, $36 million will be used to educate consumers in filing health care claim appeals. Unprecedentedly, IRS, DOL and HHS offered a joint webcast for new federal claims regulation on September 8 in preparation for the effective date of September 23, 2010.
According to Dr. Zhou, new federal claims and appeals regulations will affect every health care claims outside Medicare, including insurance benefits verification, claim submissions, eligibility for providers, pre-certification, policy coverage and limitation, medical necessity, UCR, bundling and down-coding, overpayment demand and recoupment, urgent care, pre-existing conditions, and any claim payment less than 100% as submitted. PPACA, sec. 2706 of PHS Act, specifically prohibits any discrimination against any health care providers regardless of any network participation.
ERISAclaim.com, said Dr. Zhou, will be interested in co-sponsoring, strategic alliance and networking for more seminars, certification or accreditation programs on PPACA-ERISA Claims & Appeals Regulations with other concerned organizations from billing and coding professionals, health care providers, group health plans, TPA's & IRO's. Please contact Dr. Zhou of ERISAclaim.com for further information.
ERISAclaim.com has been offering these educational Webinars, Seminars and Certifications Classes on ERISA for 10 years and on new Health Reform Laws since the Health Bill was signed into law by President Obama on 03/23/2010. These ongoing Webinars, Seminars and Certification Classes were scheduled on bi-weekly, monthly and customer request basis to teach basic, practical and expert level of appeals practice strictly in accordance with new and existing Federal Appeals Regulations for all types of claim denials and delays.
For more information, please visit http://www.erisaclaim.com/Free_ERISA_Webnars.htm, or contact Dr. Jin Zhou, president of ERISAclaim.com, at 630-808-7237.