“Overpayment”: Fraud Or Retroactive Denials? - Doctors and Hospitals Countdown V On PPACA Health Reform Laws

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ERISAclaim.com Announced 2011 PPACA Corp. Compliance – Fraud & Abuse Prevention and Appeal Programs to Assist Doctors and Hospitals in Fighting Against Increasing Improper Overpayment Recoupment and Fraud Allegations in True Retroactive Benefits Denials, and Advocating PPACA Compliance for Fraud and Abuse Prevention to Avoid True Fraud Prosecution

To stop true healthcare fraud and to refund or appeal all overpayment denials, are the true PPACA compliance.

On 03-23-2011, PPACA's first birthday, ERISAclaim.com announced 2011 PPACA Corporate Compliance – Fraud & Abuse Prevention, and Appeal Programs to assist doctors and hospitals in fighting against increasing improper overpayment recoupment and fraud allegations in true retroactive benefits denials, and advocating PPACA compliance for fraud and abuse prevention to avoid true fraud prosecution in today's mixed overpayment recoupment and anti-fraud enforcement environment. In addition, the most important goals are to set up strict PPACA Corporate Compliance Program, to increase providers’ awareness and sensitivity to the current unprecedented national civil and criminal anti-fraud enforcement, staff training and internal auditing, to prevent fraud and abuse mistakes, and to appeal all improper overpayment refund request. In 2010, the highest number of providers in the history were prosecuted and convicted for healthcare fraud, and highest amount of money in the history were recovered or recouped from the real fraud and pure overpayment retroactive denials.

ERISAclaim.com PPACA Corporate Compliance and Appeals Programs are designed to prevent intentional healthcare fraud and abuse by healthcare providers, and also to fight against health plan fiduciary fraud in violation of PPACA and ERISA Claims and Appeals Regulations, and against any intentional misrepresentation of material facts for obtaining illegitimate benefits reimbursement; and depriving consumers and healthcare providers off legitimate benefits entitlement.

Section 6402(a) of the PPACA imposes a 60-day limit to report, return and appeal any overpayment. Failure to appeal or refund may result in a "false claims" with $5,500 to $11,000 per claim penalties. In 2010 - 2011, 10% of total health expenditure or $225 billion, including intentional fraud and retroactive benefits denials, are being investigated or recouped by government and private health plans.

“For the sake of U.S. healthcare system survival, it is constitutionally important for this nation to separate true criminal and civil fraud enforcement from the genuine retroactive benefits denials for the vast majority of innocent and hard-working American workers, doctors, nurses and hospitals,” said Dr. Jin Zhou, President of ERISAclaim.com, a national expert on PPACA and ERISA Compliance and Appeals.

"Otherwise, any misguided 'antifraud enforcement' will deprive consumers and providers off their PPACA and ERISA rights to due process to appeal any retroactive adverse benefit determination, and in itself will violate federal law PPACA and ERISA, new Patient's Bill Of Rights,” added Dr. Zhou.

On March 16, 2011, the Congress released PPACA mandated GAO Report, indicating that only a very small portion of the denied claims were actually appealed (0.5% in Ohio), but if appealed, 39 to 59% appeals reversed initial denials. (http://www.gao.gov/products/GAO-11-268)

On March 4, 2011, AMA reported that 51% of doctors in TX are going broke primarily due to insurance denials and delays: “51% of Texas doctors dug into personal funds to keep practices afloat in 2010.”
“More Texas Doctors Dipping Into Personal Reserves To Keep Practices Alive” (http://www.ama-assn.org/amednews/2011/03/14/bisc0314.htm)

On February 23, 2011, Fox News Network reported that national antifraud enforcement and overpayment recoupment campaign now include intentional fraud and "gray area" of mistake-driven waste and abuse.
(http://www.foxbusiness.com/personal-finance/2011/02/23/health-reform-looks-eliminate-medical-fraud/):

“The National Healthcare Anti-Fraud Association estimates that approximately 3% of the $2.5 trillion in annual health-care spending is lost to. According to Lou Saccoccio, NHCAA executive director, the government reports an even larger figure: 10% of total health-care expenditures or $225 billion, which includes not only intentional fraud, but the grayer area of mistake-driven waste and abuse.”

On May 17, 2010, federal court permitted overpayment ERISA class action against 23 BCBS entities to proceed with providers' ERISA violation claims in overpayment recoupment dispute. (PCA v. BCBSA et al, Case 1:09-cv-05619, Document 169, Filed 05/17/10, Northern District Of Illinois)
(http://insurancenewsnet.com/article.aspx?id=192735&type=newswires)

On January 21, 2011, federal court dismissed BCBS fraud counterclaims against the providers on the basis of ERISA complete pre-emption. (PCA v. BCBSA et al, Case: 1:09-cv-05619, Document #: 343, Filed: 01/21/11, Northern District Of Illinois)

On October 17, 2010, federal court in Rhode Island dismissed BCBSRI fraud claim against two providers and converted all of BCBSRI claims into a single ERISA claim in an overpayment dispute for over $400,000 because ERISA completely pre-empts all BCBSRI’s fraud claims and breach of contract claims. (BCBSRI v. Korsen et al, Case 1:09-cv-00317-L-LDA, Document 53, Filed 10/27/10, District Of Rhode Island)

On February 16, 2011, federal court in Rhode Island permitted providers counterclaim for ERISA violation against BCBSRI and ordered BCBSRI to defend providers ERISA claims. (BCBSRI v. Korsen et al, Case 1:09-cv-00317-L-LDA, Document 68, Filed 02/16/11, District Of Rhode Island)

On March 11, 2011, MiamiHerald.com reported that “A Miami-Dade doctor was acquitted of Medicare fraud charges Friday in a sweeping home healthcare case that has so far netted more than 20 convictions through guilty plea deals.”
(http://www.miamiherald.com/2011/03/11/2111016/miami-doctor-acquitted-in-medicare.html#ixzz1Hd6m0Gyk)

January 24, 2011, HHS Reported that Health care fraud prevention and enforcement efforts recover record $4 billion; new Affordable Care Act tools will help fight fraud
(http://www.hhs.gov/news/press/2011pres/01/20110124a.html)

On 02/17, 2011, FBI reported that “Medicare Fraud Strike Force Charges 111 Individuals for More Than $225 Million in False Billing and Expands Operations to Two Additional Cities - Doctors, Nurses, Health Care Company Owners and Executives Among the Defendants Charged; Law Enforcement Agents Execute 16 Search Warrants”.     
(http://www.fbi.gov/newyork/press-releases/2011/medicare-fraud-strike-force-charges-111-individuals-for-more-than-225-million-in-false-billing-and-expands-operations-to-two-additional-cities)

“To stop true healthcare fraud and to refund or appeal all overpayment denials, the true PPACA compliance, are advocated in all ERISAclaim.com’s PPACA Compliance Programs,” concluded Dr. Zhou.

For more info on ERISAclaim.com’s new services: http://erisaclaim.com/products.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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