Supreme Court Upholds PPACA: What If Patients Still Love Their Ex-PPO Doctors?

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After the Supreme Court upheld the Patient Protection and Affordable Care Act (PPACA, or ACA) on June 28, 2012, ERISAclaim.com announced a new PPACA program: “What If Patients Still Love Their Ex-PPO Doctors?”, how PPACA protects patient rights to keep their beloved Ex-PPO doctors or hospitals, newly “divorced” from the PPO networks.

If an airline doesn’t want any one to sit in the first-class, simply stop selling for the first-class.

After the Supreme Court upheld the Patient Protection and Affordable Care Act (PPACA, or ACA) on June 28, 2012, ERISAclaim.com announced a new PPACA program, titled: “What If Patients Still Love Their Ex-PPO Doctors?”, in how PPACA protects patient rights to keep their “beloved Ex-PPO doctors” or hospitals, newly “divorced” from the PPO networks, either quitting the PPO network voluntarily or being kicked out by the PPO network involuntarily, when the managed (“marriaged”) care divorce rates are going faster nowadays than the marriage divorce rates in America. New federal PPACA law provides new protections for all Ex-PPO doctors for about 77% of insured Americans who paid for the first-class out-of-network coverage, the exact kind of coverage with higher premiums exactly for Non-PPO and Ex-PPO providers.

ERISAclaim.com’s new PPACA Ex-PPO Program is a comprehensive PPACA & ERISA compliance program covering PPACA and ERISA patient protections and appeals regulations, and Corporate Compliance, Fraud and Abuse Prevention practice to avoid allegations and litigations by Ex-PPO networks faced by most PPO and Ex-PPO providers. The two-day program is a turn-key operation in education with one day on PPACA & ERISA appeals and one day on fraud and abuse prevention for Ex-PPO’s.

More importantly, the new anti-fraud strategies will be discussed for the Ex-PPO providers to detect and deter all PPACA & ERISA fraud and abuse by PPO networks and health plans, as the compliant offense is the best defense for Patients Bills of Rights. PPACA’s new definition, for a Claimant to include his/her provider as patient’s authorized representative, practically makes Patients’ Bills of Rights same as Providers’ Bills of Rights, regardless of a PPO, Ex-PPO or Non-PPO provider:

“(iii) Claimant. Claimant means an individual who makes a claim under this section. For purposes of this section, references to claimant include a claimant’s authorized representative.”
page 43355

The landmark Supreme Court PPACA decision on June 28, 2012 upheld the constitutionality of PPACA. PPACA was signed into law by President Obama on March 23, 2010, with his pledge made on June 15, 2009 to the American Medical Association: “If you like your doctor, you will be able to keep your doctor, period. If you like your health care plan, you’ll be able to keep your health care plan, period. No one will take it away, no matter what.”

“About 77% of insured Americans paid for higher premiums for the first-class out-of-network coverage, but only about less than 5% of out-of-network claims were filed each year. The patient informed choice and rights to chose for out-of-network non-PPO or Ex-PPO providers must be the only determining factor in the market, yet the reality might be totally different. PPACA is designed to stop any types of abuse and violations of patient rights,” says Dr. Jin Zhou, President of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.

ERISAclaim.com’s new PPACA Ex-PPO Program will cover following topics:

1.    PPACA “Patient’s Bill of Rights” aka “Doctors’ Bill Of Rights:
http://cciio.cms.gov/programs/marketreforms/billofrights/index.html
2.    DOL Affordable Care Act Regulations and Guidance: http://www.dol.gov/ebsa/healthreform/
3.    PPACA Regulations on Internal Claims and Appeals and External Reviews:
4.    http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=5a02ffcbdc3b299526312c6fe4f889f8&rgn=div8&view=text&node=29:9.1.3.12.14.3.20.9&idno=29
5.    New PPACA Insurance Verification for Ex-PPO’s: Sample Completed SBC http://www.dol.gov/ebsa/pdf/SBCSampleCompleted.pdf
6.    "Federal Department Of Insurance Complaints Website" for Doctors and Patients: https://www.askebsa.dol.gov/WebIntake/Home.aspx?submit=Submit+a+Complaint
7.    Congressional GAO Reports: 39% to 59% denial reversal with valid appeals, only 0.5% appeals in Ohio - http://www.gao.gov/new.items/d11268.pdf
8.    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
9.    ACA Discount v. PPO discount.
10.    Current payer litigations against out-of-network hospitals, ASC’s and providers.

Under PPACA, the existence of out-of-network coverage is offered by the plan and paid by the patient, exactly for the non-PPO and Ex-PPO providers. No one would like to pay for the first-class, then only wanted to sit in the Economy on a plane. If an airline doesn’t want any one to sit in the first-class, simply stop selling for the first-class. In healthcare market, about 77% passengers paid for the first-class, only less than 5% would sit in the first-class. Maybe it was the patient’s choice, maybe not. If no Ex-PPO, not a choice, this is why this PPACA Program for Ex-PPO is in high demand, explained Dr. Zhou.

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, 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. Dr. Zhou were frequently consulted by and advised numerous providers and healthcare attorneys in ERISA claim appeals and health care provider ERISA class actions in the past 12 years.

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

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