2013 Emerging Trends for Out-Of-Network Health Claims: Total Claims Denial and Overpayment Recoupment

2013 Emerging Trends for Out-Of-Network Health Claims: Total Claims Denial and Overpayment Recoupment

Out-of-network providers facing total claim denials and overpayment recoupment by individual payers with respect to every patient, every health plan and every claim due to provider’s failure to disclose self- referrals and routine cost sharing waivers.

Avym Corporation announces its 2013 special compliance assistance programs for out-of-network providers faced with overpayment recoupments in the millions of dollars and total claims denials by increasing number of payers with respect to every patient, every health plan and every claim.  These denials are allegedly due to provider’s failure to disclose self-referrals and/or routine cost sharing waivers among other fraud and abuse allegations, including breach of PPO contract, billing & coding errors, and medical necessity denials.

Based on the latest research in federal and state court records, Avym has developed the 2013 Out-Of-Network Healthcare Reimbursement model (OHR).  OHR will focus on compliance risk management and solutions for all out-of-network providers.  OHR will examine the most critical and emerging trend of 2013, total claim denials from multiple payers with respect to every claim.  Avym’s OHR model will examine the reasons for these total claim denials, specifically, if and when any one payer develops evidence that a provider allegedly fails to disclose the following:

  • Significant benefit interest and/or ownership;
  • Affiliation and remuneration (as required by federal and state laws);
  • Provider network status & UCR rates;
  • Patient out-of-network/out-of-pocket liabilities;
  • Patient’s freedom to choose an alternative facility;
  • Alleged routine waivers of patient deductibles, coinsurance and co-pays;

Such evidence may also be used against out-of-network providers and may be the genesis of endless lawsuits by private insurers or payers, and possible civil and criminal enforcement actions by governmental agencies.  In addition, these out-of-network providers may also face alleged overpayment recoupments or offsets by health plans for all new patients and new claims across multiple plans, patients and providers.

“More and more out of network providers and hospitals are experiencing total claim denials and overpayment recoupments by payers.  In 2013 it is likely that most out-of-network providers will face this crisis if they are not in compliance with all disclosure laws and patient cost-sharing (deductibles, coinsurance and co-pay) liability compliance,” said Vincent Flores, President and Co-Founder of Avym Corporation.

OHR and Overpayment Recoupment and Appeals Compliance Programs are available immediately, in provider specific, private formats.   These onsite programs consist of two-day fraud & abuse prevention and compliance seminars and /or two-day ERISA / PPACA appeal compliance seminars. The programs are specifically designed for out-of-network providers facing overpayment recoupments and total claim denials by payers as well as any in-network providers that have already received PPO termination letters.

Both programs are largely developed from the most recent federal and state court records, federal court decisions in nationwide provider UCR and overpayment class actions, DOL PPACA claims regulation guidance, HHS/OIG/CMS FAQ’s, OIG advisory opinions and DOJ/FBI press releases.

“In most cases, providers that are overly confident in these new payer challenges will most likely be taken by complete surprise by the payer’s total claims denial, victory in federal courts and then possible bankruptcy”, said Dr. Zhou, president of ERISAclaim.com, and a national expert on PPACA and ERISA appeals and compliance

According to the AMA news on June 25, 2012, “Aetna sues more physicians over out-of-network pay – The court fight is part of an ongoing battle between health plans and doctors over what constitutes fair health care bills.” http://www.ama-assn.org/amednews/2012/06/25/prsb0625.htm

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.” http://www.cmanet.org/news/press-detail/?article=california-medical-association-calls-on-aetna

According To Houston Chronicle, November 7, 2012: “Federal Court Rules against BCBS in Overpayment ERISA Class Action: Providers Entitled to ERISA Appeal Rights http://www.chron.com/business/press-releases/article/Federal-Court-Rules-against-BCBS-in-Overpayment-3958959.php

The following main topics will be discussed in Avym’s 2013 special compliance assistance programs:

  1. Medicare recovery of $4.1 billion in 2011: “Health Care Fraud Prevention and Enforcement Efforts Result in Record-Breaking Recoveries Totaling Nearly $4.1 Billion” http://www.hhs.gov/news/press/2012pres/02/20120214a.html
  2. OIG Criminal and Civil Enforcement: https://oig.hhs.gov/fraud/enforcement/criminal/
  3. Health Care Fraud Prevention and Enforcement Action Team Provider Compliance Training: https://oig.hhs.gov/compliance/provider-compliance-training/index.asp
  4. DOL Affordable Care Act Regulations and Guidance: Internal Claims and Appeals and External Review: http://www.dol.gov/ebsa/healthreform/
  5. PCA v. BCBSA et. al. 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 AVYM please click here.

Located in Los Angeles, CA, AVYM is a leading provider of services focusing entirely on the resolution of denied or disputed medical insurance claims by participating in the nation’s first ERISA PPACA Claims Appeals Certification program.  AVYM also 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



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