2012 US Healthcare UCR: Supreme Court & PPACA for UCR Claims Denials for Out-of-Network Providers

Share Article

In Response to the New Demands, ERISAclaim.com Offers 2012 Advanced PPACA & ERISA Claim Specialist Programs on “UCR Claims Denials & Appeals” for All Out of Network Providers, in Compliance with the Recent Supreme Court Decisions on ERISA and PPACA Claims Regulations in 2012.

The Supreme Court, Congress and Federal Agencies have offered the new UCR protections for doctors, hospitals and patients.

In response to the new demands, ERISAclaim.com offers 2012 Advanced PPACA & ERISA Claim Specialist Programs on “UCR Claims Denials & Appeals” for all out-of-network providers, doctors, surgical centers, DME’s and hospitals, in compliance with the recent U.S. Supreme Court decisions on ERISA and the full enforcement of PPACA claims regulations in 2012. The recent Supreme Court decision, in Cigna Corp. v. Amara (No. 09-804) on May 16, 2011, has corrected the errors in remedial law under ERISA for 36 years, and has dramatically changed the ERISA legal landscape, especially for out-of-network UCR (Usual, Customary and Reasonable) denials, with "appropriate equitable relief" to remedy the “UCR violation” under ERISA section 502(a)(3). New federal heath reform law, PPACA Claims Regulation, provides new protections for wrongful UCR denials. About 77% insured Americans in private health programs paid for out of network coverage. ERISAclaim.com offers the most compliant and simplest solutions to the most common healthcare claim denials.

ERISAclaim.com 2012 “ERISA – PPACA – UCR” Programs will mainly cover (1) specific ERISA & PPACA regulations on UCR claims appeals, (2) Supreme Court decisions on the governing plan documents, applicable to UCR fee determination, and unprecedented ERISA remedies for UCR denials, (3) How to set up and rely upon the first National “UCR” Data Center from the FAIR Health, developed from the billions of de-identified healthcare claims from healthcare providers and insurers nationwide, as part of a settlement agreement reached between the New York State Attorney General’s Office and Ingenix, Inc. as well as numerous large health insurers nationwide. (4) How to file compliant ERISA & PPACA Appeals for UCR denials, (5) How to file ERISA & PPACA Complaints with DOL (“Federal Department of Insurance”) for ERISA & PPACA violations and (6) Litigation support for new PPACA Claims for new “PPACA attorneys”.

“The Supreme Court, Congress and Federal Agencies have offered the new UCR protections for doctors, hospitals and patients,” says Dr. Jin Zhou, president of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.

“Failure in ERISA compliance by all parties, providers, patients, insurers and employers, and lack of ERISA enforcement are the one of the main causes for skyrocketing U.S. healthcare expenditure in $2.6 trillions each year, in cultivating and systematically leading up to the most of the 10% of healthcare fraud, abuse and waste. The simple anti-fraud initiatives alone without the compliant appeals to protect the vast majority of the honest healthcare providers will never save our healthcare system, when more and more doctors are going broke everyday,” explained Dr. Zhou, on why this new program was developed and promoted.

ERISAclaim.com 2012 Advanced PPACA & ERISA Claim Specialist Programs on “UCR Claims Denials & Appeals” are immediately available and will mainly cover the following topics:

1.    The Supreme Court decision in Cigna Corp. v. Amara (No. 09-804) on May 16, 2011 on what document really governs benefits determination, and what new remedies available under ERISA. http://www.supremecourt.gov/opinions/10pdf/09-804.pdf
2.    DOL Kenseth Amicus Brief, in support of patient. http://www.dol.gov/sol/media/briefs/kenseth(A)-6-13-2011.htm
3.    Why Medicare Fee Schedules used for the most UCR denials are not enforceable if without ERISA compliance, even with SPD Medicare fee provisions.
4.    Why most denials (39% - 59%), including UCR denials, made without ERISA compliance are appealable and reversible. - the Congressional Report, U.S. GAO, (GAO-11-268 March 16, 2011): Private Health Insurance: Data on Application and Coverage Denials (http://www.gao.gov/products/GAO-11-268)
5.    DOL, ERISA FAQ, B1, B2, B3, B4 & B5: The plan must disclose to OON provider claimants the UCR schedules, “appropriate protocols, guidelines, criteria, rate tables, fee schedules, etc”. (http://www.dol.gov/ebsa/faqs/faq_claims_proc_reg.html)
6.     The new PPACA claims regulations to define the OON providers with a valid Designation of Authorized Representative as a Claimant, regardless of network participation, to receive direct reimbursement checks and appeal rights as well as access to the plan’s entire claim file, including UCR data base. (http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=5a02ffcbdc3b299526312c6fe4f889f8&rgn=div8&view=text&node=29:
7.    DOL Website - PPACA Claim Regulation and Guidance: http://www.dol.gov/ebsa/healthreform/
8.    EBSA News Release: US Department of Labor’s EBSA creates new consumer assistance Web page [11/10/2011] http://www.dol.gov/opa/media/press/ebsa/EBSA20111627.htm
9.    "Federal Department Of Insurance Complaints Website" for Doctors and Patients: https://www.askebsa.dol.gov/WebIntake/Home.aspx?submit=Submit+a+Complaint
10.    How to set up a defendable and reasonable UCR fee schedule in a simplest way, by using FAIR Health’s “FH Medical Cost Lookup”, simply replacing the zip code 60133 and CPT code 99203 with yours in this link: (http://fairhealthconsumer.org/medicalcostlookup/cost.aspx?loc=60133&term=99203&zip=60133)
11.    Why “UCR” from FAIR Health in 2012? http://fairhealthconsumer.org/faq.aspx
12.    DOL: About 77% of Insured Americans Purchased Out-Of-Network Coverage under Private Industry (DOL, BLS, NBS 2010, page 11 of 167): http://stats.bls.gov/ncs/ebs/detailedprovisions/2010/ebbl0047.pdf

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

Located in a Chicago suburb in Illinois, for over 11 years, 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 numerous pending national ERISA class action 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.

# # #

Share article on social media or email:

View article via:

Pdf Print

Contact Author

Jin ZHou
Visit website