Our healthcare system must strike a balance between putting real criminals behind the bars and protecting the vast majority of honest patients and healthcare providers.
Hanover Park, IL (PRWEB) January 09, 2012
In response to the new demands, ERISAclaim.com offers 2012 Advanced SIU ERISA & PPACA Appeals Programs to prevent disastrous revenue loss of year-long claims or bankruptcy as a result of a payer's SIU Investigation with noncompliance of ERISA and PPACA. Providers nationwide are increasingly and epidemically under the payer’s SIU (Special Investigation Unit) Investigation, without proper compliance with PPACA and ERISA claims regulations, for both purported or alleged healthcare fraud, and prepayment reviews, post-payment audit with overpayment refund demand, as pre-service claim denials, prospective and retrospective benefits claim denials, without disclosing and affording providers or patients the ERISA & PPACA rights to appeal. While months or years later, even without discovering any fraud by SIU, the year-long claims would be denied in the federal court for the provider’s failure to timely file ERISA appeals, inevitably resulting in disastrous revenue loss in year-long claims or frequently provider bankruptcies.
“While it is perfectly legitimate for a health plan fiduciary to safeguard plan assets and fight against all healthcare fraud and abuse, it is also extremely important for health plan fiduciary to comply with ERISA fiduciary duties and claims regulation, “solely in the interest of the participants and beneficiaries” under 29 U.S.C. §1104, Fiduciary duties. It is clear that no one can wear two hats at the same time by playing a Guardian Angel as a fiduciary and an investigator as a prosecutor simultaneously. Our healthcare system must strike a balance between putting real criminals behind the bars and protecting the vast majority of honest patients and healthcare providers,” says Dr. Jin Zhou, president of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.
“It is encouraging to see that federal government and the private industry antifraud initiatives have resulted in billions of dollars in recovery from the pure fraud and put many real criminals behind bars. It is also shocking to see that many more times the innocent and honest healthcare providers are going broke as a result of the purported fraud investigation by payer SIU, for totally legitimate and pure coverage and the medical necessity denials, because it is practically impossible that every SIU case is pure fraud,’ cautioned Dr. Zhou.
From analyzing the recent court cases, it is clear that both health plans and providers must make more efforts in stepping up healthcare fraud and abuse prevention and enforcement. But at the same time, it is also extremely important to separate the pure fraud investigation from the pure legitimate benefits determination in claim denials and appeals, in compliance with ERISA and PPACA, explained Dr. Zhou on why this Advanced SIU ERISA & PPACA appeals program was developed due to the high practical demands.
ERISAclaim.com 2012 Advanced SIU ERISA & PPACA Appeals Programs are immediately available and will cover the following topics:
1. Healthcare fraud and abuse awareness, education, compliance and effective prevention;
2. Mixed, ambiguous, implied or alleged healthcare fraud vs. pure benefits determination or claim denials & delays;
3. How to consult with a healthcare attorney immediately for any alleged or implied healthcare fraud, and how to file timely ERISA and PPACA appeals for every claim denials and delays, regardless of SIU;
4. USA Today: Health care fraud prosecutions on pace to rise 85%. (http://www.usatoday.com/news/washington/story/2011-08-29/Health-care-fraud-prosecutions-on-pace-to-rise-85/50180282/1)
5. HHS, OIG: Health Care Fraud Prevention and Enforcement Action Team Provider Compliance Training. (http://oig.hhs.gov/compliance/provider-compliance-training/index.asp)
6. HHS, OIG: Health Care Compliance Program Tips: The Seven Fundamental Elements of an Effective Compliance Program and Five Practical Tips for Creating A Culture of Compliance. (http://oig.hhs.gov/compliance/provider-compliance-training/files/Compliance101tips508.pdf)
7. Final Compliance Program Guidance for Individual and Small Group Physician Practices: “D. The Difference Between ‘Erroneous’ and ‘Fraudulent’ Claims To Federal Health Programs” (http://oig.hhs.gov/authorities/docs/physician.pdf)
8. PPO or ERISA? Christie v. Aetna, (Case 4:10-cv-01766), SDTX, 11/22/2011. PPO is not even triggered unless ERISA is resolved or moot. (http://ww1.prweb.com/prfiles/2012/01/01/9071951/Christie%20v%20Aetna%20Health.pdf)
9. No one can wear two hats under ERISA fiduciary duties, with conflict of interest as a fiduciary breach under 29 U.S.C. §1104.( http://www.gpo.gov/fdsys/pkg/USCODE-2010-title29/html/USCODE-2010-title29-chap18-subchapI-subtitleB-part4-sec1104.htm)
10. DOL Website - PPACA Claim Regulation and Guidance: http://www.dol.gov/ebsa/healthreform/
11. 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
12. "Federal Department Of Insurance Complaints Website" for Doctors and Patients: https://www.askebsa.dol.gov/WebIntake/Home.aspx?submit=Submit+a+Complaint
13. How to file effective complaint with DOL for all violation of ERISA and PPACA claim regulations.
14. How to file timely, effective and compliant ERISA and PPACA appeals while under SIU investigation, SIU prepayment review, and SIU post payment audit with overpayment demand to preserve your rights, for your monthly, yearly revenue in denied, delayed claims or already paid claims.
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.