PPACA & ERISA: 2012 Out-of-Network ASC And Hospital Reimbursement Laws & Overpayment Crisis

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ERISAclaim.com Announces 2012 PPACA & ERISA Claim Specialist Certification Programs for Out-of-Network (OON) Providers, Surgical Centers & Hospitals, In Compliance with New Federal Healthcare Reform Laws, PPACA, As Solutions To The OON Reimbursement and Overpayment Crisis

PPACA & ERISA are the preeminent federal laws governing health claims, especially OON provider claims.

ERISAclaim.com announces 2012 PPACA & ERISA Claim Specialist Certification programs for out-of-network (OON) providers, ambulatory surgical centers (ASC) & hospitals. The Certification Programs are designed to train providers to comply with new federal healthcare reform laws, PPACA, and new U.S. Supreme Court decisions on ERISA, and are provided as new solutions to the escalating OON reimbursement and overpayment crisis. The key topics the Certification Programs will include: OON providers’ rights to receive insurance checks directly, rightful UCR reimbursement rates under PPACA and ERISA, patients’ rights to choose OON providers and PPACA & ERISA protections against all alleged overpayment recoupment and payer SIU pre-payment review delays and denials.

The Advanced 2012 PPACA & ERISA Claim Specialist Certification programs will offer new OON Compliance Training to prevent and defend against the most prevalent healthcare payer fraud allegations, claim denials and delays which include: cost sharing fraud (co-pay & deductible waiver), billing & coding fraud (upcoding and unbundling), medical necessity fraud and documentation fraud.

In 2012, the Patient Protection And Affordable Care Act (PPACA) claims regulations will be fully implemented and enforced for all health plans, as well as the majority all healthcare claims outside of Medicare and Medicaid programs.

PPACA adopted the 36-year-old federal law ERISA, in its entirety, as minimum standards for all health plans. ERISAclaim.com’s PPACA & ERISA Claim Specialist Program is the first and only program in the nation developed for healthcare providers and reimbursement professionals.

“PPACA & ERISA are the preeminent federal laws governing health claims, especially OON provider claims. The latest Congressional study reported a 39% to 59% reversal of claim denials if appealed under ERISA, but only less than 0.5% of denials were appealed in the state of Ohio. The lack of ERISA education and ERISA Compliant appeals is a primary reason providers turned to questionable or even alleged fraudulent claims practices,” says Dr. Jin Zhou, president of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.

ERISAclaim.com 2012 PPACA & ERISA Claims Specialist Certification program is supported by Congressional GAO report and prompted by New Federal PPACA Claim Regulations, explained Dr. Zhou.

United States Government Accountability Office (GAO) - Data on Application and Coverage Denials: http://www.gao.gov/new.items/d11268.pdf

DOL PPACA Regulations and Guidance: http://www.dol.gov/ebsa/healthreform/

On Sept 23, 2011, the federal District Court in New Jersey dismissed all out-of-network provider plaintiffs UCR class action claims against CIGNA and UnitedHealthcare solely based on the poor and limited ERISA Assignment of Benefits. Franco v. Connecticut General Life Ins. Co. (Case 2:07-cv-06039-SRC–PS) was filed in federal court, District of New Jersey, as one of the largest UCR class actions after the UnitedHealthcare UCR settlement, by several patients, numerous out-of-network providers, several provider State Associations and the American Medical Association (AMA), alleging violations of the ERISA for wrongful UCR denials and reimbursement.

In particular, among other things, the Court concluded the following:

“All ERISA claims asserted by Provider Plaintiffs in the CAC and North Peninsula Complaint will accordingly be dismissed.” (Case 2:07-cv-06039-SRC -PS Document 638 Filed 09/23/11 Page 20 of 82 PageID: 25499)

A copy of complete court decision is available at: http://ERISAclaim.com/Franco_v_CIGNA.pdf

2012 PPACA & ERISA Claim Specialist Certification Programs will cover the following topics:

1.    U.S. Supreme Court ERISA decision in Cigna v. Amara (Case No. 09–804) on May 16, 2011- the most significant changes in healthcare ERISA legal landscape for providers reimbursement rights to receive rightful UCR and checks directly;
2.    New PPACA Claims Regulations, effective 09/23/2010, and fully implemented in 2012 for all health plan claim denials and appeals.
3.    Examination of the court’s factual and legal analysis and conclusion of traditional healthcare providers decade old Assignment of Benefits in one of the largest out-of-network provider UCR class action lawsuits against CIGNA and UnitedHealthcare.
4.    ERISA claim regulations: the 36-year-old federal law governing all health claims for all employer sponsored health plans, including all claim denials, delays, post-payment overpayment recoupment / withhold, pre-payment SIU reviews.
5.    DOL ERISA FAQ’s for all claims denials and delays, ERISA prompt pay and UCR protections.
6.    Reimbursement focused, proactive and pre-emptive healthcare compliance, fraud and abuse prevention programs, for all current and popular fraud and abuse allegations faced by most providers, especially OON, as the integrated and most effective reimbursement fraud prevention and defense practices for alleged overpayment recoupment and pre-payment review delays and denials.

To find out more about the Total PPACA Claims and Appeals Compliance Services from ERISAclaim.com:

Located in a Chicago suburb in Illinois, for over 11 years, ERISAclaim.com is the only ERISA & PPACA consulting, publishing and website resource for healthcare providers in the country. ERISAclaim.com offers free webinars, basic and advanced educational seminars and on-site claims specialist certification programs for doctors, hospitals and commercial companies, as well as numerous pending national ERISA class action litigation support. Dr. Jin Zhou is regarded as the industry “Godfather of ERISA claims” for healthcare providers.

For any questions, please contact Dr. Jin Zhou, president of ERISAclaim.com, at 630-808-7237.

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