39% to 59% denial reversal could be a making or breaking point for most healthcare providers and hospitals for fair, accurate and legally entitled reimbursement on behalf of their patients.
Hanover Park, IL (Vocus/PRWEB) March 17, 2011
On March 16, 2011, Federal Government released it long waited report - U.S. GAO: Private Health Insurance: Data on Application and Coverage Denials. Nationwide data collected by HHS from insurers indicated that 39% to 59% of appeals reversed original coverage denials. This GAO report is especially timely important when new federal claims and appeals regulations under health reform laws, PPACA, are in counting down for full enforcement deadline on July 01, 2011 after the initial effective on Sep. 23, 2010. ERISAclaim.com offers free Webinars to examine GAO Report and the PPACA Claims Specialist Certification Training Programs to lead the nation up to a new healthcare century, 39% to 59% denial reversal under new Federal Claims Regulations, PPACA.
“39% to 59% denial reversal could be a making or breaking point for most healthcare providers and hospitals for fair, accurate and legally entitled reimbursement on behalf of their patients, in order to sustain current U.S. healthcare system”, said Dr. Jin Zhou, President of ERISAclaim.com, a national expert in PPACA & ERISA Appeals and Compliance.
“One of the real healthcare crises is that most healthcare providers and their billing staff are not educated on federal laws in their ineffective appeals and lack of real enforcement by federal government on non-compliance with federal claims regulations, ERISA”, added Dr. Zhou.
U.S. GAO, (GAO-11-268 March 16, 2011): Private Health Insurance: Data on Application and Coverage Denials, reports the following in part (http://www.gao.gov/products/GAO-11-268):
“Further, the data GAO reviewed indicated that coverage denials, if appealed, were frequently reversed in the consumer's favor. For example, data from four of the six states on the outcomes of appeals filed with insurers indicated that 39 percent to 59 percent of appeals resulted in the insurer reversing its original coverage denial. Data from a national study conducted by a trade association for insurance companies on the outcomes of appeals filed with states for an independent, external review indicated that coverage denials were reversed about 40 percent of the time. GAO provided a draft of the report to HHS and the Department of Labor (DOL).”
In addressing to HHS Secretary Kathleen Sebelius and Labor Secretary Hilda L. Solis in the magnitude of this report in connection with PPACA, GAO states:
“A large majority of Americans—nearly 64 percent as of 2009—rely on private insurance for health care coverage, most through employer-sponsored group health coverage. With the enactment of the Patient Protection and Affordable Care Act (PPACA) in March 2010, enrollment in private health insurance could expand significantly, particularly for individuals and families that do not have access to group coverage through their employer.”
A copy of the GAO full report is available at: http://www.gao.gov/new.items/d11268.pdf
A copy of the GAO Highlights Page is available at: http://www.gao.gov/highlights/d11268high.pdf
PPACA Claims & Appeals Regulations govern all group health plans, ERISA and non-ERISA, and individual market claims. July 01, 2011 is the deadline as full enforcement grace period for PPACA since its effective date on Sept. 23, 2010.
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 (http://webapps.dol.gov/FederalRegister/HtmlDisplay.aspx?DocId=24056&AgencyId=8&DocumentType=2)
“SUMMARY: This document contains interim final regulations implementing the requirements regarding internal claims and appeals and external review processes for group health plans and health insurance coverage in the group and individual markets under the Patient Protection and Affordable Care Act. The regulations will generally affect health insurance issuers; group health plans; and participants, beneficiaries, and enrollees in health insurance coverage and in group health plans. The regulations provide plans and issuers with guidance necessary to comply with the law.
DATES: Effective date. These interim final regulations are effective on September 21, 2010.”
“(iii) Claimant. Claimant means an individual who makes a claim under this section. For purposes of this section, references to claimant include a claimant's authorized representative.”
PPACA’s new definition for claimant makes PPACA a new federal Provider’s Bill of Rights, as any healthcare provider with a valid designation of an authorized representative, regardless of participating status with managed care networks, is now legally regarded as a claimant, with same rights as the patient, explained Dr. Zhou.
PPACA claims regulations will govern all claims processing, reimbursement, denials and appeals for almost all healthcare claims outside Medicare and Medicaid, the most significant reimbursement law changes in 45 years since Medicare was created.
Complete PPACA Claims and Appeals Regulations and Guidance can be found on DOL website: http://www.dol.gov/ebsa/healthreform/
ERISAclaim.com provides basic and advanced expert training for providers and hospitals to become PPACA Claims Specialists.
Located in a Chicago suburb in Illinois, 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 litigation support. Dr. Jin Zhou is regarded as the industry “Godfather of ERISA claims” for healthcare providers.
For schedules and registration of these free PPACA / ERISA Webinars: http://www.erisaclaim.com/Free_ERISA_Webnars.htm
For a free PPACA Webinar for your Organization or Institution, please contact Dr. Jin Zhou, President of ERISAclaim.com, at 630-808-7237.
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