PPACA Protects 35,000 Ex-PPO Doctors in California Managed Care Earthquakes

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The 10th PPACA Claims Specialists Certification Programs Were Announced in Los Angeles by ERISAclaim.com, for 35,000 Ex-PPO CMA Member Doctors, Already or Soon-to-be Divorced from the Aetna PPO Networks, in A War for Patient’s “Right to Choose” or “Right to Save” Between CMA and Aetna

Patients are increasingly choosing to go out of networks with their in-network deductibles beyond their ability to pay and with the PPO Forms informing their rights to choose

The 10th PPACA Claims Specialists Certification Programs were announced today in Los Angeles by ERISAclaim.com, in order to assist 35,000 Ex-PPO CMA member doctors, already or soon-to-be divorced from the Aetna PPO Networks, in an Aetna v. CMA war for patient’s “right to choose” or “right to save” between California Medical Association (CMA) and Aetna. The PPACA Program on Sept 15, 2012 in LA is timely, in the wake of the CMA Press and the LA Times Report last week, allegedly confirmed by Aetna, that Aetna is terminating or kicking out all 35,000 members of CMA as a result of the on-going court battles. The PPACA Ex-PPO Programs were designed to provide 35,000 California doctors with the most compliant solutions to patient’s rights to choose and protections under the new federal health reform law, PPACA, Patient Protection and Affordable Care Act. On June 28, 2012, the Supreme Court upheld the PPACA’s constitutionality.

ERISAclaim.com’s 10th 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 currently 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 all PPO and Ex-PPO’s providers.

“The California Aetna v. CMA Managed Earthquake appears to be a war on patient’s rights to choose or to save, but this is clearly the evidence of the beginning of the end of the U.S. managed business model when the patient in-network deductibles are greater than their monthly salaries and the providers’ profits are less than the costs of doing business. PPACA is constitutionally transforming the old PPO model to the new ACO or ACA models in an unprecedented California style of the healthcare earthquakes unfolded last week,” says Dr. Jin Zhou, president of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.

According to a LA Times Report on 08-30-2012, “Dispute between Aetna, California Medical Assn. heats up: California Medical Assn. accuses insurer Aetna of refusing to negotiate with member doctors or kicking doctors out of its network as retaliation for a lawsuit.”

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.”

“We do not pass any judgment on the merits of the court allegations from Aetna or CMA. That judgment is entrusted to the Courts. We provide only PPACA compliant solutions for providers to fully and proper disclose any self-referrals and out-of-network referrals in accordance with all applicable federal and state laws, and to act as the patient’s advocates for patient’s right to choose and to appeal all claim delays and denials under ERISA and PPACA,” says Dr. Zhou.

“Patients are increasingly choosing to go out of networks with their in-network deductibles beyond their ability to pay and with the PPO Forms informing their rights to choose,” commented Dr. Zhou.

As reported by an American Medical Association news report on June 26, 2012, according to the Kaiser’s Health Security Report in June 2012: “Insured, High-Income Patients Delay Medical Care, Too: Even among people who make $90,000 or more per year, nearly 40% skipped or delayed care because of cost”.

“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,” says Vincent Flores, a certified PPACA and ERISA Claim Specialist, co-founder of AVYM Corporation in Los Angeles, California. (http://avym.com/)

ERISAclaim.com’s 10th PPACA Ex-PPO Program will cover following topics:

1.    DOL Affordable Care Act Regulations and Guidance: http://www.dol.gov/ebsa/healthreform/
2.    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
3.    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
4.    ACA Indigency Discount v. PPO discount: http://archive.hhs.gov/news/press/2004pres/20040219.html
5.    Disclosures on estimated charge for each service & all services, network participation status, billing and collection policies.
6.    Guaranteed Patient Satisfaction (GPS) for total disclosure and transparency on referring provider affiliation and remuneration arrangement, if any.
7.    PPACA/ERISA appeal assistance for both in-network and out of network claim delays and denials.
8.    OIG HEALTH CARE COMPLIANCE PROGRAM TIPS: http://oig.hhs.gov/compliance/provider-compliance-training/files/Compliance101tips508.pdf

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

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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