U.S. Supreme Court: ERISA for No. 1 Health Claim Denials and Litigations in 2012 – Cost-Sharing War

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In the wake of recent explosive insurer litigations, claim denials and auditing against healthcare providers and patients solely due to alleged deductible and co-insurance waiver practice, ERISAclaim.com offers compliance webinars on the latest Supreme Court decisions, PPACA and ERISA regulations.

Health plans and insurer’s litigations can not be said to be all without any merits.

In the wake of recent nationwide explosive insurer litigations, claim denials and auditing against healthcare providers solely due to alleged deductible and co-insurance waiver practice by providers, ERISAclaim.com offers healthcare executive compliance webinars on the latest Supreme Court decisions, PPACA and ERISA regulations for compliance and solutions to the looming, booming and forthcoming No. 1 U.S. health claim denials and litigations in 2012.

ERISAclaim.com Webinars will cover the following topics: (1) The relevant recent Supreme Court decisions for 77% of the insured Americans under the employer sponsored health plans in booming explosive claims denials, audits, litigations as the forthcoming No. 1 U.S. healthcare dispute involving health plans, providers and patients. (2) New federal health reform law, PPACA claim regulations adopted federal ERISA law as the minimum claim regulations for all health plans and individual market claims, (3) For 36 years, ERISA claim regulation provides very specific provisions regulating the “circumstances which may result in disqualification, ineligibility, or denial or loss of benefits”, such as cost-sharing waiver practice faced by every patient and provider, (4) compliant or non-compliant practice for waiver of cost-sharing.

“In reviewing 2012 healthcare headline news, it is evident that No. 1 payor and provider litigations and claim dispute are now explosively escalating to the top of the radar screen, “deductible and co-insurance war” for all”, said Dr. Jin Zhou, President of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.

“While health care providers are being sued for not collecting patient deductible in the west coast and but for collecting patients deductible and denied claims in the east coast, health plans and insurer’s litigations can not be said to be all without any merits. The nationwide explosive and mass claim auditing and litigations should have prompted all of us to ask one simple question: what do Supreme Court, PPACA and ERISA regulations say about this new billion dollar question?,” explained Dr. Zhou, for why this new Webinar was urged by providers.

Of importance in particular, ERISAclaim.com healthcare executive webinar will have in-depth discussion on compliant cost-sharing waiver practices, and when and why the claims can or can not be denied for cost-sharing waivers and reductions:

1.    HHS/OIG Guidance on compliance for cost-sharing waivers and reductions: http://archive.hhs.gov/news/press/2004pres/20040219.html

2.    ERISA requires the administrator of an employee benefit plan to give participants a Summary Plan Description (SPD) and a summary of any material modifications (SMM) that are "sufficiently accurate and comprehensive to reasonably apprise [them] * * * of their rights and obligations under the plan." (http://www.gpo.gov/fdsys/pkg/USCODE-2010-title29/html/USCODE-2010-title29-chap18-subchapI-subtitleB-part1-sec1022.htm)

3.    “The Summary Plan Description shall contain the following information: “circumstances which may result in disqualification, ineligibility, or denial or loss of benefits;” 29 U.S.C. 1022(b);

4.    The SMM must provide notice of changes in those circumstances, 29 U.S.C. 1022(a);

5.    The SPD and SMM must "be written in a manner calculated to be understood by the average plan participant," 29 U.S.C. 1022(a);

6.    SPD and SMM must not have the effect [of] misleading, misinforming or failing to inform participants." 29 C.F.R. 2520.102-2(b). 29 U.S.C. 1024(b).

7.    ERISA Civil enforcement: (a) Persons empowered to bring a civil action A civil action may be brought—(1) by a participant or beneficiary……(B) to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan; 29 U. S. C. §1132(a)(1)(B); (http://www.gpo.gov/fdsys/pkg/USCODE-2010-title29/html/USCODE-2010-title29-chap18-subchapI-subtitleB-part5-sec1132.htm)

8.    Recent Supreme Court decision on participant right and plan authority under ERISA, for cost-sharing disputes. Kennedy v. Plan Administrator for Dupont Savings and Investment Plan et al. (No. 07–636), 01/26/2009. “ERISA provides no exception to the plan administrator’s duty to act in accordance with plan documents. Thus, the Estate’s claim stands or falls by “the terms of the plan,” 29 U. S. C. §1132(a)(1)(B), a straight for-ward rule that lets employers “ ‘establish a uniform administrative scheme, [with] a set of standard procedures to guide processing of claims and disbursement of benefits,’ ”

9.    Latest U.S. Supreme Court decision for all ERISA claims: “Cigna v. Amara, (No. 09-804), 05/16/2011. “We conclude that the summary documents, important as they are, provide communication with beneficiaries about the plan, but that their statements do not themselves constitute the terms of the plan”. (http://www.supremecourt.gov/opinions/10pdf/09-804.pdf)

10.    PPACA & ERISA claim regulations on claim denials and appeals due to deductible and co-insurance waiver dispute and litigations. (http://www.dol.gov/ebsa/healthreform/)

To find out more about PPACA Claims and Appeals Compliance Services from ERISAclaim.com:
http://www.erisaclaim.com/products.htm

Located in a Chicago suburb in Illinois, 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.

Dr. Jin Zhou & ERISAclaim.com were nominated for White House Champions of Change PPACA Program in 2012 for educating others about the new health care law to raise awareness about the benefits of the Patient Protection & Affordable Care Act (PPACA). (http://www.sfgate.com/cgi-bin/article.cgi?f=/g/a/2012/02/11/prweb9189619.DTL)

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

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