July 1, 2011 - U.S. Hospitals' PPACA Readiness for New Federal Claims & Appeals Laws

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ERISAclaim.com Announced Its Preliminary Internet Research Results On The U.S. Hospitals' PPACA Readiness By July 1, 2011, For The Official Enforcement On Health Reform PPACA Claims & Appeals Regulations, In A Follow-Up With A Congressional GAO PPACA Report Published On March 16, 2011.

PPACA claims regulations under healthcare reform law should be the No. 1 priority for every hospital......

July 1, 2011, the PPACA claims & appeals regulations enforcement date, is less than 30 days away. ERISAclaim.com announced its preliminary Internet search results on the U.S. Hospitals' PPACA readiness by July 1, 2011, for the official enforcement on health reform PPACA claims & appeals regulations 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 (PPACA). This study is also in a follow-up with a Congressional GAO PPACA report published on March 16, 2011. PPACA claims and appeals regulations are the most sweeping reimbursement law changes since the enactment of Medicare 45 years ago.

This preliminary Internet search revealed less than 0.001% education and implementation on PPACA & ERISA Claims & Appeals Regulations by about 5,815 hospitals, millions of healthcare providers and providers’ Associations (including AMA, AHA & HFMA).

“PPACA claims regulations under healthcare reform law should be the No. 1 priority for every hospital, as PPACA protects hospitals’ claims reimbursement and revenue cycle, for almost all non-Medicare and Medicaid claims,” said Dr. Jin Zhou, President of ERISAclaim.com, a national expert on PPACA & ERISA appeals and compliance.

This preliminary Internet search was designed to assess the PPACA readiness of U.S. hospitals to appeal for the delayed or denied health claims by fully trained PPACA & ERISA Claim Specialist or PPACA Appeals Department, as provided under PPACA.

ERISAclaim.com's PPACA market research is in response to and a follow-up with a Congressional GAO PPACA report published on March 16, 2011, with findings that very small portion of denied claims were ever appealed (0.5% in Ohio), but if appealed, 39% to 59% appeals reversed initial denials.

Why ERISAclaim.com Did This Study?

PPACA required GAO to study the rates of coverage denials and appeals. ERISAclaim.com did this follow-up study to assess the PPACA readiness of hospitals and providers by July 01, 2011.

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):

Why GAO Did This Study?

"The large percentage of Americans that rely on private health insurance for health care coverage could expand with enactment of the Patient Protection and Affordable Care Act (PPACA) of 2010. Until PPACA is fully implemented, some consumers seeking coverage can have their applications for enrollment denied, and those enrolled may face denials of coverage for specific medical services. PPACA required GAO to study the rates of such application and coverage denials. GAO reviewed the data available on denials of (1) applications for enrollment and (2) coverage for medical services.”

“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.”

“Reversals of coverage denials were limited to denials for which an appeal was initiated. The data we reviewed did not allow for a systematic calculation of an “appeal rate”—the number of coverage denials for which an appeal was initiated—for several reasons, including different data sources or data years for denials and appeals data. Data from Ohio did provide limited information; specifically, for the first quarter of calendar year 2010, Ohio data indicated that 0.5 percent of claim denials were internally appealed.”

“Please note that GAO reports that ‘Reversals of coverage denials were limited to denials for which an appeal was initiated’, a non-ERISA appeal, non-PPACA appeal or a ‘provider inquiry’ won’t count as an appeal”, explained Dr. Zhou.

On March 23, 2010, President Obama signed PPACA into law. PPACA claims and appeals regulations went into effect on September 23, 2010. PPACA adopts ERISA claim regulation in its entirety, with 7 new requirements, as the minimum PPACA internal appeal standards. PPACA adopts NAIC external appeal model, with 16 new standards, as PPACA federal and state external appeal standards. http://webapps.dol.gov/FederalRegister/PdfDisplay.aspx?DocId=24056

On September 20, 2010, the Departments, DOL, HHS & IRS, issued a Technical Release (TR #2010-02) to extend enforcement grace period until July 1, 2011 for certain new PPACA internal appeal standards. http://www.dol.gov/ebsa/newsroom/tr10-02.html

On March 18, 2011, the Departments issued another Technical Release (TR # 2011-01) to minimize both cost and delay, to avoid confusion for participants and plans alike. The TR #201101 seeks to avoid enforcing standards that the Departments intend to modify in the near future, by extending enforcement grace period, in part only for three new standards, until January 1, 2012, which are insignificant for healthcare providers.

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

Since the enactment of PPACA on March 23, 2010, ERISAclaim.com has offered the Total PPACA Claims & Appeals Compliance Services for doctors and hospitals, including education and implementation for PPACA claims specialists and PPACA appeals department, claims recovery and litigation support, for billing coding staff, supervisor, manager, director, CFO, in-house counsel and outside billing companies as well as outside litigating attorneys.

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.

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

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

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