PPACA & ERISA: Navigating Reimbursement Laws and Loopholes


ERISAclaim.com announces 2012 Patient Protection And Affordable Care Act (PPACA) and Employee Retirement Income Security Act (ERISA) claim specialist certification programs for out-of-network (OON) providers, ambulatory surgical centers and hospitals. The certification programs are designed to train providers to comply with new federal healthcare reform laws, PPACA and new U.S. Supreme Court decisions on ERISA, and are provided as new solutions to the escalating OON reimbursement and overpayment crisis. The key topics the certification programs will include: OON providers' rights to receive insurance checks directly, rightful UCR reimbursement rates under PPACA and ERISA, patients' rights to choose OON providers, and PPACA and ERISA protections against all alleged overpayment recoupment and payor SIU pre-payment review delays and denials.

The Advanced 2012 PPACA and ERISA claim specialist certification programs will offer new OON compliance training to prevent and defend against the most prevalent healthcare payor fraud allegations, claim denials and delays which include: cost sharing fraud (co-pay & deductible waiver), billing and coding fraud (upcoding and unbundling), medical necessity fraud and documentation fraud.

In 2012, the PPACA claims regulations will be fully implemented and enforced for all health plans, as well as the majority of all healthcare claims outside of Medicare and Medicaid programs.

PPACA adopted the 36-year-old federal law ERISA, in its entirety, as minimum standards for all health plans. ERISAclaim.com's PPACA and ERISA claim specialist program is one of only programs in the nation developed for healthcare providers and reimbursement professionals.

"PPACA and ERISA are the pre-eminent federal laws governing health claims, especially OON provider claims. The latest congressional study reported a 39 percent to 59 percent reversal of claim denials if appealed under ERISA, but only less than 0.5 percent of denials were appealed in the state of Ohio. The lack of ERISA education and ERISA-compliant appeals is a primary reason providers turned to questionable or even alleged fraudulent claims practices," says Dr. Jin Zhou, president of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.

ERISAclaim.com 2012 PPACA and ERISA claims specialist certification program is supported by a congressional Government Accountability Office (GAO) report and prompted by new federal PPACA claim regulations, Zhou explains.

For GAO data on application and coverage denials, visit www.gao.gov/new.items/d11268.pdf. For DOL PPACA regulations and guidance, see www.dol.gov/ebsa/healthreform/.

On Sept. 23, 2011, the federal District Court in New Jersey dismissed all out-of-network provider plaintiffs UCR class action claims against CIGNA and UnitedHealthcare solely based on the poor and limited ERISA Assignment of Benefits. Franco v. Connecticut General Life Ins. Co. (Case 2:07-cv-06039-SRC-PS) was filed in federal court, District of New Jersey, as one of the largest UCR class actions after the UnitedHealthcare UCR settlement, by several patients, numerous out-of-network providers, several provider state associations and the American Medical Association (AMA), alleging violations of the ERISA for wrongful UCR denials and reimbursement.

In particular, among other things, the court concluded the following: "All ERISA claims asserted by Provider Plaintiffs in the CAC and North Peninsula Complaint will accordingly be dismissed." (Case 2:07-cv-06039-SRC -PS Document 638 Filed 09/23/11 Page 20 of 82 PageID: 25499)

Specifically, the 2012 PPACA and ERISA claim specialist certification programs will cover the following topics:

1. U.S. Supreme Court ERISA decision in Cigna v. Amara (Case No. 09-804) on May 16, 2011– the most significant changes in healthcare ERISA legal landscape for providers reimbursement rights to receive rightful UCR and checks directly.
2. New PPACA claims regulations, effective Sept. 23, 2011, and fully implemented in 2012 for all health plan claim denials and appeals.
3. Examination of the court's factual and legal analysis and conclusion of traditional healthcare providers decade old Assignment of Benefits in one of the largest out-of-network provider UCR class action lawsuits against CIGNA and UnitedHealthcare.
4. ERISA claim regulations: the 36-year-old federal law governing all health claims for all employer sponsored health plans, including all claim denials, delays, post-payment overpayment recoupment/withhold, pre-payment SIU reviews.
5. DOL ERISA FAQs for all claims denials and delays, ERISA prompt pay and UCR protections.
6. Reimbursement focused, proactive and pre-emptive healthcare compliance, fraud and abuse prevention programs, for all current and popular fraud and abuse allegations faced by most providers, especially OON, as the integrated and most effective reimbursement fraud prevention and defense practices for alleged overpayment recoupment and pre-payment review delays and denials.


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