2013 Out-of-Network Health Claims: Total Claims Denials and Overpayment Recoupment

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ERISAclaim.com announced its 2013 special compliance assistance programs for all out-of-network providers already faced with overpayment recoupment and total claims denials by certain payers for every patient, every health plan and every claim, due to the alleged provider failure to disclose in self- referrals and routine waivers.

when a provider is most overly confident in these new payer challenges, this provider will most likely be totally surprised by the payer’s victory in the federal courts and total claims denials, and then possible bankruptcy

November 8, 2012, ERISAclaim.com announced its 2013 special compliance assistance programs for all out-of-network providers already faced with overpayment recoupment in millions of dollars and total claims denials by more and more payers for every patient, every health plan and every claim, due to the alleged provider failure to disclose in self-referrals and/or routine waivers, among other fraud and abuse allegations, including breach of PPO contract, billing & coding errors, and medical necessity denials.

From the latest research in the federal and state court records, ERISAclaim.com also announced its 2013 out-of-network healthcare reimbursement model, with compliance risk management & solutions for all out-of-network providers: total claims denial from multiple payers for every patient, every health plan and every claim, if any one payer developed any evidence that a provider allegedly failed to disclose any significant benefit interest, ownership, affiliation and remuneration as required by federal and state laws, provider out of network status & UCR rates, patient out-of-network out-of-pocket liabilities, patient alternative freedom of choice, and allegedly routinely waived patient deductibles, coinsurance and co-pay. These out-of-network providers are also faced with alleged overpayment recoupment or offset by health plans from all new patients and new claims from across plans, across patients and across providers. These out-of-network providers may also be faced with endless lawsuits by private insurers or payers, and possible civil and criminal enforcement actions by governmental agencies.

ERISAclaim.com’s Overpayment Recoupment, and Total Claims Denials & Appeals Compliance Programs are immediately available, in provider specific, private and onsite format, designed with two-day fraud & abuse prevention and compliance seminars and /or two-day ERISA / PPACA appeal compliance seminars. They are especially for all out-of-network providers already faced with overpayment recoupment and total claim denials by payers, and for any in-network providers who have already received PPO termination letters.

The two-day ERISA / PPACA appeal compliance seminars are also for every healthcare provider, because (a) on June 28, 2012 the Supreme Court upheld the Patient Protection and Affordable Care Act (PPACA, or ACA), (b) PPACA adopts and mandates ERISA claims regulation in its entirety, and (c) PPACA claims regulations went into effect on Sept 23, 2010 and will be fully implemented in 2013 as federal mandates for all health plans and insurers, and all health care providers for all healthcare claims denials and appeals.

Both programs and seminars are mainly developed from the most recent HHS/OIG, DOJ/FBI press releases, HHS/CMS FAQ’s, OIG advisory opinions, federal and state court records, DOL PPACA claims regulation guidance and federal court decisions in the nationwide provider UCR and overpayment class actions.

“More and more out of network providers and hospitals have experienced total claims denials and overpayment recoupment by certain payers for months and years. In 2013, it is likely that most out-of-network providers will be faced with this crisis if they are not fully in compliance with all disclosure laws and patient cost-sharing (deductibles, coinsurance and co-pay) liability compliance,” said Dr. Zhou, president of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.

“In most cases, when a provider is most overly confident in these new payer challenges, this provider will most likely be totally surprised by the payer’s victory in the federal courts and total claims denials, and then possible bankruptcy,” added Dr. Zhou.

According to the AMA news on June 25, 2012, “Aetna sues more physicians over out-of-network pay - The court fight is part of an ongoing battle between health plans and doctors over what constitutes fair health care bills.” http://www.ama-assn.org/amednews/2012/06/25/prsb0625.htm

As reported on 08-30-2012 by a Press Release from CMA, California Medical Association, “California Medical Association calls on Aetna to stop retaliatory behavior against physicians”. Dr. James T. Hay. M.D., CMA president, was quoted as saying: “Aetna is essentially saying that they will no longer do business with the 35,000 members of CMA.” http://www.cmanet.org/news/press-detail/?article=california-medical-association-calls-on-aetna

According To Houston Chronicle, November 7, 2012: “Federal Court Rules against BCBS in Overpayment ERISA Class Action: Providers Entitled to ERISA Appeal Rights”
http://www.chron.com/business/press-releases/article/Federal-Court-Rules-against-BCBS-in-Overpayment-3958959.php

The following main topics will be discussed with 2013 ERISAclaim.com solutions:

1.    Medicare recovery of $4.1 billion in 2011: “Health Care Fraud Prevention and Enforcement Efforts Result in Record-Breaking Recoveries Totaling Nearly $4.1 Billion” http://www.hhs.gov/news/press/2012pres/02/20120214a.html
2.    OIG Criminal and Civil Enforcement: https://oig.hhs.gov/fraud/enforcement/criminal/
3.    Health Care Fraud Prevention and Enforcement Action Team Provider Compliance Training: https://oig.hhs.gov/compliance/provider-compliance-training/index.asp
4.    DOL Affordable Care Act Regulations and Guidance: Internal Claims and Appeals and External Review: http://www.dol.gov/ebsa/healthreform/
5.    PCA v. BCBSA et. al.: http://ww1.prweb.com/prfiles/2012/10/18/10028942/PCA%20v%20BCBSA.pdf

To find out more services and products from ERISAclaim.com:
http://www.erisaclaim.com/products.htm

Located in a Chicago suburb in Illinois, for over 12 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.

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