Overpayment Fraud Or SIU / TPA Fraud? – Health Plans Countdown On PPACA Health Reform Laws

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ERISAclaim.com Announced 2011 PPACA Health Plan Compliance Programs – Fraud & Abuse Prevention, And Plan Assets Audit And Recovery, To Assist Health Plans In PPACA Compliance In The Practice Of Overpayment Recovery, To Review Recent Federal Court Class-Action Rulings And To Recover Plan Assets From TPA’s In The $225 Billion Overpayment Recovery Market.

PPACA prohibits overpayment recoupment or offsetting without strict compliance with PPACA and ERISA.

On 03-23-2011, PPACA 1st birthday, ERISAclaim.com announced 2011 PPACA Health Plan Compliance Programs – Fraud & Abuse Prevention, And Plan Assets Audit and Recovery, to assist health plans in PPACA & ERISA compliance, in the practice of overpayment recovery, for new PPACA full and fair review standards, no conflict of interest standards and continued coverage standards (prohibiting overpayment recoupment and offsetting without PPACA compliance) as well as Feds recent PPACA enforcement guidance on the effective dates; to review recent federal court rulings in providers’ overpayment ERISA class-action against 23 BCBS entities; and to recover plan assets from TPA’s successful overpayment recovery, in the $225 billion overpayment recovery market, with increasing federal criminal investigation into the widespread plan assets embezzlement under DOL Contributory Plan Criminal Project.

“The purpose and goals for our programs are to advocate for strict PPACA and ERISA compliance”, said Dr. Jin Zhou, a national expert on PPACA and ERISA compliance.

ERISAclaim.com’s 2011 PPACA Health Plan Compliance Programs will cover following topics and are mainly based on the statutory provisions in (A)(1)(2)(3)(4) of PHS Act Sec. 2719 of PPACA and PPACA regulatory provisions in (a)(2)(i)(b)(2)(i)(ii)(A)(C)(D)(iii) of 26 CFR 54.9815-2719T, 29 CFR 2590.715-2719, 45 CFR 147:
(http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_public_laws&docid=f:publ148.pdf) (PPACA Statute)
(http://webapps.dol.gov/FederalRegister/PdfDisplay.aspx?DocId=24056) (PPACA Claims and Appeals Regulations)

1.    PPACA defines overpayment determination as an adverse benefits determination.
2.    PPACA adopts ERISA claims regulation in its entirety as PPACA minimum internal appeal standards.
3.    PPACA imposes new full and fair review and conflict of interest standards in internal and external appeals for claim processing and overpayment recovery.
4.    PPACA prohibits overpayment recoupment or offsetting without strict compliance with PPACA and ERISA.
5.    DOL, HHS & IRS PPACA Enforcement Guidance on March 18, 2011.
6.    How to separate true civil and criminal fraud investigation from genuine overpayment recovery as pure retroactive adverse benefit determination and fiduciary reviews.
7.    How to avoid SIU/TPA and Plan violations of PPACA and ERISA full and fair review & no conflict of interest standards in employing a SIU (Special Investigation Unit) or TPA performing fraud investigation and financial recovery functions in the capacity of plan fiduciary, as SIU or TPA will have appearance of and structure in conflict of interest when performing full and fair reviews and complete disclosures of fiduciary claim review and simultaneously in civil or criminal fraud investigations. ((2)(ii)(D) of 29 CFR 2590.715-2719)
8.    For self-insured health plans, how to supervise SIU / TPA overpayment recovery practice to avoid any violation of PPACA and ERISA, federal investigation of noncompliance, and avoid lawsuit by patients or class-action by providers;
9.    For self-insured health plans, how to audit and recover plan assets when former and current TPA’s successfully recovered undisputed overpayment in hundreds of millions of dollars;
10.    How to safeguard plan assets from possible TPA plan asset embezzlement in overpayment recovery.

On March 18, 2011, DOL, HHS & IRS (Departments) released a new Technical Release No. 2011-01 (http://www.dol.gov/ebsa/newsroom/tr11-01.html), as new PPACA claims regulations enforcement Guidance, ensuring no administrative enforcement extension or delays for PPACA Claims Regulations' effective date on September 23, 2010, except for 3.5 minor new standards, out of 7 new standards, (Standards #2, #5, #7, & #6, such as 24-hour decision-making for urgent care claims, Spanish or Chinese Notices or possible AIDS/HIV diagnosis and abortion treatment on Notices), which are practically moot issues for the overpayment recovery, according to Dr. Zhou.

On February 23, 2011, Fox News Network reported that “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.” (http://www.foxbusiness.com/personal-finance/2011/02/23/health-reform-looks-eliminate-medical-fraud/)

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 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)

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 11/16/2010, DOL announced Contributory Plans Criminal Project against Plan Assets Embezzlement.
(http://www.dol.gov/ebsa/newsroom/fscpcp.html & http://www.dol.gov/ebsa/newsroom/criminal/main.html)

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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