ObamaCare(s) for Provider’s “Overpayment” Nightmares: Feds Issues New PPACA “Overpayment Denial” Laws - Overpayment Law Reviews by ERISAclaim.com

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On March 1, 2013, DOL released a new Guidance for PPACA (aka ObamaCare) Coverage and Claims Appeals Regulations for all improper overpayment recoupment denials. ERISAclaim.com announced new overpayment law reviews on this DOL PPACA guidance, DOL overpayment Court Briefs, recent Supreme Court and District Court overpayment decisions.

PPACA is commonly known as “ObamaCare” or “ObamaCares”, depending upon if YOU really care, says Dr. Jin Zhou

On March 1, 2013, DOL released a new Self-Compliance Guidance for PPACA (a.k.a. ObamaCare) Coverage and Claims Appeals Regulations for all improper claim denials, especially overpayment recoupment and withholding denials. On March 4, 2013, ERISAclaim.com announced new overpayment law reviews on this DOL PPACA Guidance, DOL overpayment Court Brief on November 30, 2012, recent Supreme Court on February 25, 2013 and District Court overpayment decision on October 12, 2012. In addition, ERISAclaim.com announced its 2013 PPACA & ERISA Overpayment Appeal and Litigation Support Programs in compliance with PPACA and ERISA to advocate for Patient Bill of Rights against all improper adverse benefit determination, in overpayment demand denials for post-payment claims and overpayment withholding denial for new patient claims.

The entire DOL Self Compliance Tools may be found at DOL website:

“PPACA is a federal law, stands for Patient Protection and Affordable Care Act. PPACA was upheld as constitutional by the Supreme Court on June 28, 2012. PPACA is commonly known as “ObamaCare” or “ObamaCares”, depending upon if YOU really care. Now every provider must understand ObamaCares for provider’s overpayment recoupment nightmares, the No. 1 health care claim denial in 2013,” says Dr. Jin Zhou, president of ERISAclaim.com, a national expert on PPACA and ERISA compliance, and a well recognized expert in ERISA overpayment appeals and provider class-action litigation support.

Any alleged post-payment overpayment repayment demand is an ERISA and PPACA denial, and an overpayment withholding or offsetting from a new patient is another ERISA and PPACA denial. A post-payment overpayment repayment demand due to retroactive rescission of policy coverage is a PPACA and ERISA denial, any medical necessity and billing or coding dispute are ERISA and PPACA denials. Any PPO discount, and pure fraud allegations are not ERISA denials. Without offering and completing PPACA and ERISA appeals, a patient or provider is fully protected from any repayment demand and offsetting or withholding from new claims, as simplified and demystified by Dr. Joe (Zhou).

On March 1, 2013, in issuing PPACA Claims Appeals Regulations Self Compliance Tools for all self-insured plans and group insurance issuers, DOL provides this new Guidance for PPACA definition of adverse benefits determination to include retro-active overpayment repayment demand, retro-active rescission of insurance coverage, any refund or payment resulting less than 100% payments as totally claimed; PPACA definition of Claimant, (a.k.a. Provider Bill Of Rights) to include a healthcare provider as a claimant’s authorized representative. PPACA Claims Appeals Regulations adopt ERISA claim regulations in its entirety as PPACA minimum internal appeals standards.

On November 30, 2012, in the Federal Appeals Court for the Third Circuit, DOL filed an overpayment Court Brief, with the most comprehensive clarification and interpretation of ERISA claim regulation: ERISA governs any and all overpayment repayment demands and new payment withholding denials as a result of any plan coverage dispute; each and every overpayment demand and/or repayment withholding constitute an adverse benefit determination under ERISA for every old and new claim and/or patient; every health plan must provide a patient or provider with ERISA compliant benefits notification (EOB) and full and fair reviews; a patient or provider shall insist upon his/her ERISA rights to challenge all overpayment repayment demand or withholding of new patient claims in an appeal process that complies with ERISA claims regulation.

More importantly and timely, ERISAclaim.com will review a most recent Supreme Court decision on February 25, 2013, that finalized a lawsuit against United Healthcare for out-of-network providers, over the “the scope of liability of an ERISA plan administrator and fiduciary for allegedly misrepresenting a plan beneficiary’s coverage in its advice to a provider of health devices.” (UHC v. AMQ, Case No.: 12-806) http://www.supremecourt.gov/Search.aspx?FileName=/docketfiles/12-806.htm

As an unprecedented compliance program, ERISAclaim.com announced its 2013 PPACA & ERISA Overpayment Appeal and Litigation Support Programs in accordance with the first federal district court decision on October 12, 2012, in favoring the class-action providers and against the health plan’s motion for summary judgment as a matter of law, because the Court concludes that (1) federal law ERISA, rather than provider PPO contract, governs the payors’ overpayment dispute based on medical necessity or plan coverage dispute; (2) any and all overpayment repayment demand due to medical necessity and plan coverage dispute constitute an ERISA adverse benefit determination, commonly known as a denial; (3) health plan payer’s SIU (Special Investigation Unit) recovery practice evidently failed to comply with ERISA claim regulation in failing to provide providers with ERISA compliant benefits notification (EOB) and ERISA full and fair reviews with consulting with appropriate health care professionals for medical necessity determination and de novo review by plan fiduciaries in provider’s appeals; and (4) providers have valid ERISA Assignment of Benefits and are entitled to pursue ERISA litigation in federal court.
(PCA et al. v. BCBSA et al., Case: 1:09-cv-05619, United States District Court, N.D. Illinois, decided on October 12, 2012.) http://ww1.prweb.com/prfiles/2012/10/18/10028942/PCA%20v%20BCBSA.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.

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

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