Federal PPACA Claim Laws for Out-of-Network Doctors & Hospitals – Same Rights as In-Network Providers

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ERISAclaim.com Announced 2001 New Health Reform Law, PPACA, Webinars & Seminars For All Out-Of-Network Doctors & Hospitals: Same Rights For Receiving Reimbursement Checks, EOB's, Plan Documents, Verifying Coverage, Appeals, Emergency Service Coverage And More, As In-Network Providers.

On April 18, 2011, ERISAclaim.com announced 2001 new Health Reform Law, PPACA, Webinar & Seminars for All Out-Of-Network Doctors & Hospitals: same rights for receiving reimbursement checks, EOB'S, plan documents, verifying coverage, appeals, emergency service coverage and more, as in-network providers. Healthcare reform law, PPACA, went into effect on September 23, 2010. PPACA outlawed the industry decade-long managed-care anti-assignment practice that discriminated against all out-of-network providers in receiving direct reimbursement checks and appeal rights when the coverage for out-of-network providers existed for the 73% of insured hard-working Americans. ERISAclaim.com’s PPACA / ERISA program is the nation’s only educational and consulting program for out-of-network providers, providing a turnkey solution for all compliant forms and letters, in order to get paid directly from health plans, to offer patients same or better indigent discount than PPO discount in compliance with federal and state laws, and secure checks from the patients in case health plan failed to comply with PPACA laws. The webinar is free to all. The seminars will be conducted with a turnkey solution package with all necessary PPACA/ERISA forms and letters.

“Out-of-network providers are guaranteed under PPACA with same rights as in network providers. Our PPACA compliance program is strictly developed in accordance with statutory and regulatory provisions, rather than personal expectations," said Dr. Jin Zhou, President of ERISAclaim.com, a national expert in PPACA and ERISA appeals and compliance.

“PPACA claims regulations have gone into effect since September 23, 2010 and adopted ERISA in its entirety as the minimum PPACA internal appeals standards,” explained Dr. Zhou, “for the first time in U.S. healthcare history, federal law, PPACA, defined a claimant solely based on the patient personal designation of his/her Authorized Representative, rather than provider’s participation of managed care networks. And more importantly, PPACA outlawed managed care anti-assignment practice for all group health plans outside Medicare and Medicaid programs and individual policies market in all 50 states”.

ERISAclaim.com’s PPACA / ERISA Webinars and Seminars for Out-Of-Network Doctors and Hospitals will cover following topics:

1.    New federal health reform law, Patient Protection and Affordable Care Act, PPACA, went into effect on September 23, 2010;
2.    PPACA adopted federal law ERISA claim regulation in its entirety as the minimum PPACA internal claims standards for disbursement of reimbursement checks and claimant status for any appeals;
3.    PPACA defines claimant to include healthcare providers as authorized representatives;
4.    U.S. Supreme Court rulings on ERISA beneficiaries and disbursement of reimbursement checks;
5.    Congressional Report from Recent HHS and DOL That 82.1% of Large Health Plans (greater than 500) are self-insured (http://aspe.hhs.gov/health/reports/2011/LGHPstudy/index.shtml);
6.    “Seventy percent of insured working Americans pay higher premiums for insurance plans that allow them to use out-of-network doctors” (http://www.ag.ny.gov/media_center/2009/jan/jan13a_09.html);
7.    The importance of, and how to become an Authorized Representative under ERISA of and PPACA, to act on behalf of the patients, as the claimant, to receive reimbursement checks directly and exercise the same rights as patients regardless of network participation;
8.    The importance of, and how to offer indigent discount, better than PPO discount, in compliance with all federal and state laws, in order to avoid "no out-of-pocket waiver" fraud allegations and health plan’s audit;
9.    The importance of, and how to put the health plan on PPACA & ERISA notice of assignment of benefits, demand health plans compliance in disbursement of reimbursement checks directly to providers;
10.    The importance of, and how to secure patient compliance to bring insurance check to you through PPACA and ERISA compliant financial guarantee/collateral agreement

Complete PPACA Regulations and Guidance can be found on DOL website:

PPACA Claims and Appeals Regulations define a healthcare provider with valid designation of authorized representative as a claimant regardless of network participation status:

“(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.” [Page 43355]

On March 18, 2011, DOL, HHS & IRS issued the second enforcement guidance to clarify that No Delays For 99% PPACA Claims & Appeals Laws, except for ONLY 3 minor standards, “to avoid enforcing standards that the Departments intend to modify in the near future.” (http://www.dol.gov/ebsa/newsroom/tr11-01.html)

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 “69% had cash flow problems because payments from government and private insurers arrived late, below what was billed, or not at all.” AMA - “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)

For more information on the PAPCA for non-PPO program: http://www.erisaclaim.com/Non_PPO_Checks.htm

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


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