Supreme Court Decision Likely to Award Billions of Dollars in TPA Refunds to More Self-insured Plans

On November 5, 2014, only 15 days after the high court’s denial of BCBSM’s appeal, a federal district court in Michigan lifted a previous stay order for one of the more than 50 similar pending cases. The federal district court in Michigan reopened a separate but identical case after the U.S. Supreme Court, on Oct. 20, 2014, rejected BCBSM appeal of a $6.1 million fraud judgment in favor of a self-insured plan.

Pursuant to the HHS, OIG and the National Health Care Anti-Fraud Association’s conservative estimate, at least 3 percent—or more than $60 billion each year—is lost to fraud, in the current $3 trillion annual healthcare expenditure.

Additionally, in accordance with the Supreme Court Hi-Lex decision and the reopening of pending cases, all self-insured health plans nationwide should look to recover at least $30 to $45 billion in refunds from the past 10 years of successful plan assets TPA/ASO anti-fraud recoupments and managed care savings in the private sector.

“Failure to safeguard plan assets is definitely a fiduciary breach under ERISA, and now the Supreme Court has given us a legal formula for plan assets recovery, a timely and true resolution to today’s U.S. healthcare crisis,” says Dr. Jin Zhou, president of ERISAclaim.com, a national expert and the “ERISA Godfather” in ERISA healthcare compliance and medical claim appeals.

As the DOL ramps up audits and enforcement actions in health plan claims and appeals, every ERISA self-insured health plan sponsor or fiduciary should keep in mind that they are required to monitor TPA/ASOs successful overpayment recoveries and managed care savings, in order to determine whether:

  • any of the billions of dollars of successful TPA/ASO overpayment recoupments and offsets nationwide each year are ERISA plan assets;
  • all TPA/ASOs must refund all ERISA plan assets as ERISA prohibits all self-dealings;
  • all self-insured plan administrators are liable for fiduciary breach in failing to safeguard or recover plan assets.

As illustrated by the Supreme Court decisions and the reopening of similar cases, it is extremely critical for all self-insured health plans and TPAs to understand the implications of the Supreme Court decision rejecting BCBSM’s $6.1 million appeals. Moreover, the high court’s decision will likely have a multi-billion dollar impact on all self-insured plans.

Avym Corporation demystifies this high court decision with new 2015 ERISA Fiduciary TPA Auditing & Plan Assets Recovery Programs designed to enable self-insured health plans in the recovery of potentially billions of dollars in similar TPA/ASO hidden fees. These advanced Recovery Programs can assist all self-insured plans recover all hidden fees in TPA/ASO overpayment recoupments and managed care savings and are based on the Supreme Court’s new interpretation of ERISA plan assets, fiduciary and ERISA prohibited transactions and self-dealings with respect to the managed care industry and ASO contracting practices.

On Oct. 20, 2014, the U.S. Supreme Court announced: “Petition DENIED”, and ultimately declined all appeals of BCBSM’s $6.1 million fraud judgment in favor of a self-insured ERISA plan by the U.S. Court Of Appeals for the Six Circuit, upholding the decision by the District Court for the Eastern District of Michigan. (http://www.supremecourt.gov/Search.aspx?FileName=/docketfiles/14-168.htm.)

Supreme Court Case Info: Blue Cross Blue Shield of Michigan, Petitioner v. Hi-Lex Controls, Inc., et al., Case No. 14-168, Docketed: August 14, 2014, Lower Ct: United States Court of Appeals for the Sixth Circuit, Case Nos.: (13-1773, 13-1859), Decision Date: May 14, 2014

The high court announced its decision, without comments, on October 20, 2014 that it will not review a ruling by the U.S. Court of Appeals for the Sixth Circuit in Cincinnati, concluding:

BCBSM committed fraud by knowingly misrepresenting and omitting information about the Disputed Fees in contract documents”,

after it affirmed a District Court decision, in May 2013, concluding that Michigan’s largest health insurer violated the Employee Retirement Income Security Act (ERISA) in ERISA prohibited transactions and ERISA fraud by concealing BCBSM’s hospital claims markup as much as 20% and pocketed the overcharge for over 20 years, according to the Supreme Court website: (http://www.supremecourt.gov/Search.aspx?FileName=/docketfiles/14-168.htm.)

On November 5, 2014, only 15 days after the high court decision on October 20, 2014, the federal district court in Michigan lifted a previous stay order for one of the more than 50 similar cases pending in the same court. (Fisher & Company, Inc. et al v. Blue Cross and Blue Shield Michigan, U.S. District Court, Eastern District of Michigan (Detroit), CIVIL DOCKET FOR CASE #: 2:13-cv-13221-GER-MAR.)

On November 5, 2014, the district court explained its decision to reopen the pending case:

On May 14, 2014, the U.S. Court of Appeals for the Sixth Circuit issued its opinion in the Hi-Lex Conrols matter, affirming the district court’s judgment. Hi-Lex Controls, Inc. v. Blue Cross Blue Shield of Mich., 751 F.3d 740 (6th Cir. 2014). BCBSM timely filed a petition for a writ of certiorari to the United States Supreme Court on August 12, 2014, and the Supreme Court denied the petition on October 20, 2014. Blue Cross Blue Shield of Mich. v. Hi-Lex Controls, Inc., cert. denied, 83 U.S.L.W. 3109, 2014 WL 3965217 (U.S. Oct. 20, 2014) (No. 14-168)….Accordingly, IT IS HEREBY ORDERED that Plaintiffs’ Motion to Lift Stay (Dkt. # 19) is GRANTED and that this matter is REOPENED.,

according to court documents.

To find out more about Avym’s 2015 ERISA Fiduciary TPA Auditing & Plan Assets Recovery Programs or to contact us about educational programs please click here.

To sign up for our newsletter and become an Avym Insider please click here.

Federal Appeals Court Sides with Out-of-Network Providers and Patients

On Nov. 5, 2014, federal Court of Appeals ruled for out-of-network provider’s ERISA right to sue UnitedHealth on behalf of patients for out-of-network deductible waiver claim denials. In a much anticipated case, the 9th Circuit sided with Spinedex Physical Therapy USA Inc., saying the clinic had standing to sue because the plan beneficiaries had assigned them their rights.

This case represents the first shot over the bow at insurer’s attempts to limit payments to providers and discourage patient out-of-network utilization based on patient deductibles and co-pays.

The court rejected defendant UnitedHealth’s argument, and explained that an out-of-network provider has ERISA rights for payment and to sue–and whether a provider balance bills a patient, after the assignment when seeking payment from the health plan, is irrelevant. This is a clear court victory for all out-of-network patients and providers.

The federal Court of Appeals for the Ninth Circuit in California ruled for the plaintiff out-of-network provider’s ERISA right to sue UnitedHealth on behalf of patients for out-of-network deductible waiver claim denials, because

Defendants point out that Spinedex has not sought payment from its patients for claims, or portions thereof, that United and the Plans have refused to pay.

All out-of-network providers must understand this court decision as it affects both patients and providers, with an increasing number of out-of-network deductible waiver claim denials.

Avym Corp. announces new ERISA out-of-network claims specialist special training programs in accordance with this federal appellate court decision:

It also included a statement in which patients acknowledged that they were liable for all costs of the services rendered…….But the patients’ injury in fact after the assignment is irrelevant. As assignee, Spinedex took from its assignors what they had at the time of the assignment. At the time of the assignment, Plan beneficiaries had the legal right to seek payment directly from the Plans for charges by non-network health care providers.

according to court documents.

Case Info: Spinedex Physical Therapy USA, et al v. United Healthcare of Arizona et al, Case No. 12-17604, in the United States Court of Appeals for the Ninth Circuit, filed on Nov. 5, 2014.

Regardless of upfront deductible or co-pay collection after the assignment, an out-of-network provider has ERISA rights to sue for payment from an ERISA health plan, as long as the provider has a valid patient ERISA assignment and establishes the patient’s legal obligation to pay. Deductible and Co-Pay waiver claim denial has been the No. 1 out-of-network claim denial reason, with an increasing number of out-of-network patient bankruptcies as a result of the national epidemic and disastrous three-invoice patient collections practice. Approximately 76% of Americans insured through their employer-sponsored health plans have paid for out-of-network coverage, according to the December 2013 National Composition Summary from DOL Bureau of Labor Statistics.

This historical out-of-network case is a classic example of the most pressing issue facing out-of-network patient and providers across the nation.  The scenario plays out every day: the health plan will usually deny all out-of-network claims for alleged out-of-network deductible and coinsurance waivers by a provider, and allegedly the patient “has not suffered injury in fact”, then the health plan is not liable for any payment to the provider. This is usually followed by alleged overpayment requests and unauthorized offsets.

In Spinedex, United Healthcare denied all out-of-network claims:

Defendants point out that Spinedex has not sought payment from its patients for claims, or portions thereof, that United and the Plans have refused to pay. Defendants argue that because Spinedex has not sought payment from its assigning patients for any shortfall, those patients do not have the “injury in fact” necessary for Article III standing. Defendants argue that since Spinedex stands in the shoes of, and can have no greater injury than, its assignors, Spinedex has not suffered injury in fact.”

The court rejected defendant Unitedhealthcare’s argument, and explained that an out-of-network provider has ERISA rights for payment and to sue and whether a provider balance bills a patient, after the assignment when seeking payment from the health plan, is irrelevant. The court explained why:

We are aware of no circuit court that has accepted defendants’ argument. …… The flaw in Defendants’ argument is that they would treat as determinative Spinedex’s patients’ injury in fact as it existed after they assigned their rights to Spinedex. We agree with Defendants that Spinedex has not sought to recover from its patients any shortfall in Spinedex’s recovery from the Plans, and that the patients have not suffered injury in fact after assigning their claims. But the patients’ injury in fact after the assignment is irrelevant. As assignee, Spinedex took from its assignors what they had at the time of the assignment. At the time of the assignment, Plan beneficiaries had the legal right to seek payment directly from the Plans for charges by non-network health care providers. If the beneficiaries had sought payment directly from their Plans for treatment provided by Spinedex, and if payment had been refused, they would have had an unquestioned right to bring suit for benefits.

While Defendant United Healthcare prevailed in certain other claims, the Ninth Circuit concluded:

We hold that Spinedex had Article III standing to bring benefit claims against Defendants as assignee of its patients. Its injury in fact is the same injury its assignees had at the time of the assignment.

The best explanation for out-of-network ERISA patient protections is from DOL, Obama administration’s Amicus brief and oral arguments in this case:

Thousands of healthcare claims are made in this country every day, and some are litigated, and yet no circuit court has ruled that providers must first bill their patients before they may enforce legitimately assigned benefits claims. …. Limiting physicians’ first recourse to their patients will have chilling effects both on providers and plan participants. Participants may forgo or delay vital healthcare because they cannot finance or they cannot pay for their care, and providers may limit their care to those participants whose health plans have previously paid properly assigned healthcare claims or participants who are able to first to pay for the care, or the provider can recognize as creditworthy.

according to court audio records.

DOL oral argument recording can be heard HERE

For a case summary click HERE

Avym is dedicated to providing plaintiff providers with ERISA appeal compliance and ERISA litigation support in all cases as well as ERISA class actions.  All medical providers and Plans should understand several critical issues regarding the profound impact of this final court decision on the nation’s No. 1 health care claim denial – overpayment demand recoupment and offsetting; including how to correctly appeal every wrongful overpayment demand and subsequent claims offsetting with valid ERISA assignment and the first ERISA permanent injunction.  In addition, when faced with pending litigation and or offsets or recoupments, providers should look for proper litigation support against all wrongful overpayment recoupment and offsetting, to seek for enforcement and compliance with ERISA & PPACA claim regulations.

For more information or to contact AVYM, click HERE

Aetna Class Action-Aetna Sued for Overpayment Offsets in Violation of ERISA and for “Illegal Self Help” Designed to Circumvent ERISA

On October 24, 2014, Aetna was slapped with a new provider class-action lawsuit alleging ERISA violations and fraud for its overpayment recoupment and offset practice. The suit also alleges Aetna engaged in withholding or offsetting new payments from providers as part of an “enterprise level” scheme of “illegally” withholding payments for covered services.

Case Info: MAYER-et-al-v.-AETNA-INC.-et-al U.S. District Court for the Central District of CA Civil Docket For Case #: 2:14-cv-08266, Filed 10/24/14.

This class action comes on the heels of another overpayment provider class action lawsuit filed against United Healthcare (UHC) on June 23, 2014. In that case, the overpayment recoupment and offset practices of UHC are alleged to be in violation of ERISA and fiduciary fraud. Avym’s support services were instrumental in allowing multiple plaintiffs the chance to fight back.

Overpayment offset and recoupments continue to be the Healthcare provider industry’s No. 1 claim denial as evidenced by UHC’s own admission that it had recovered $430 million worth of overpayments in 2011 alone. Correspondingly, for self-insured health plans, the No. 1 hidden cost is overpayment recoupment and possible plan assets embezzlement. In another recent case that intertwines ERISA violations and hidden fees, the U.S. Supreme Court rejected an appeal by BCBSMI of a lower court’s ruling which awarded a self-insured ERISA health plan a $6.1 million fraud judgment. The immediate impact of all these cases could be billions of dollars for all self-insured ERISA health plans nationwide, as a result of the ASO/TPA industry’s potential recovery of a billion dollars in overpayment recoupments and anti-fraud campaigns over the past 10 years.

This Aetna case illustrates the need for all employer sponsored health plans to comply with federal ERISA regulations when making demands for overpayment refunds. Attempts to recoup or withhold monies from providers are and should be treated as any other claim denials.  Additionally, Providers need to level the playing field by ensuring they submit ERISA/PPACA compliant appeals which properly request due process and a full and fair review.

According to the lawsuit,

  • Aetna has been withholding or offsetting new payments in part or in whole from providers from one patient to satisfy another alleged overpayment in the past from other unidentified and completely separate patients in violation of ERISA;
  • Aetna then misleads patients and the plan sponsors as to payments made to the providers by claiming that a “payment” had been “issued” when in fact it was not paid;
  • Aetna has never complied with ERISA claims regulation when requesting alleged overpayments and offsetting new payments from other patients.

The putative class on behalf of all similarly situated providers is seeking for ERISA benefits payments due, injunctive and declaratory relief. The provider class action also alleges additional ERISA violations by Aetna for withholding and offsetting newly adjudicated claim payments from one patient to satisfy another alleged overpayment in the past from other unidentified patients which in some cases are members of a completely separate plan, in violation of ERISA.

The complaint also alleges that Aetna misled patients and the plan sponsors on patient EOB’s that indicated “payment” had been “issued”, when in truth and in fact no such payment was ever made to the providers, according to the Court Complaint.

In particular, the complaint alleged the following:

“Aetna is engaged in an enterprise-level scheme whereby it illegally withheld such payments. It did so in order to offset what it believes to be prior overpayments to Plaintiffs made by different Aetna Plans relating to services provided to different Aetna Insureds. It has done so without any legal authority under the Aetna Plan or otherwise, and leaves the Aetna Insureds financially responsible for unpaid bills for Covered Services that their respective Aetna Plans are obligated to pay”

The complaint goes on to allege that:

Instead of availing itself of lawful means of recovering such overpayments under ERISA, Aetna instead engages in illegal self-help designed to circumvent the ERISA regulatory regime. Neither the Aetna Insureds, their ONET providers, nor the language of the Aetna Plans granted Aetna the rights to recover alleged overpayments in this manner”.  The Plaintiffs also allege that Aetna “did not provide any of the informational items or appellate procedures mandated by the ERISA Claims Procedure.”

As more and more of these cases make their way through the courts, it is clear that the previously questionable or “legal gray area” of overpayment recoupment practices engaged in by many of the nation’s biggest insurance carriers, effectively trigger ERISA appeal rights.  Insurers and Health Plans will be forced to comply with all applicable federal laws, ERISA and PPACA claims regulations, as well as statutory fiduciary duties before recouping one single dollar. Providers or patients that face Aetna or any payor recoupments or offsets would do well to understand the implications of these lawsuits as well as their rights under ERISA.

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 services.

US SUPREME COURT DECISION ON BCBS APPEAL COULD POTENTIALLY RETURN BILLIONS OF DOLLARS TO SELF-INSURED PLANS

On Sep. 15, 2014, in the United States Supreme Court, Blue Cross Blue Shield Association, et al. filed an Amici Curiae Brief in support of BCBSM, appealing a Sixth Circuit Court award of $6.1 million to a self-insured plan. The implications of this Supreme Court decision could potentially return billions of dollars to self-insured health plans across the nation.

In a new twist about a case we have written about before, Hi-Lex Controls v. BCBSM, the BCBS Association has enlisted the help of insurance industry associations America’s Health Insurance Plans (AHIP) and Pharmaceutical Care Management Association (PCMA) in petitioning the US Supreme Court to overturn the lower court’s ruling that the insurer allegedly perpetrated fraud against its customers for nearly 20 years, namely for violating ERISA’s prohibition against self-dealing and breaching its fiduciary duties as well as engaging in fraud and concealment to hide its violations from plaintiffs.

If the Supreme Court upholds the Sixth Circuit decision of $6.1 million award for just one self-insured plan, the immediate impact could be billions of dollars for all self-insured ERISA health plans nationwide, as a result of the TPA industry’s potential recovery of a billion dollars in overpayment recoupments and anti-fraud campaigns over the past 10 years.

Avym Corporation announces new advanced ERISA Embezzlement Recovery Programs in preparation of the forth-coming Supreme Court decision, which will have a multi-billion dollar impact on self-insured health plans nationwide.  Specifically the advanced programs will examine the following issues: (1) determine if any TPA overpayment recoupments and offsets, which are in the billions of dollars nationwide, are ERISA plan assets, (2) ensure all TPA’s properly refunded ERISA plan assets as ERISA prohibits all self-dealings, (3) communicate and clarify self-insured plan administrator’s potential liability for fiduciary breach in failing to safeguard or recover plan assets.

These groundbreaking TPA/ASO auditing programs are unique and unlike any other traditional self-insured health plan overpayment auditing programs and are designed to identify and recover alleged overpayments that have been recouped by the TPAs –but have not been disclosed, restored or refunded to the ERISA self-insured plan assets as required under ERISA statutes and fiduciary responsibilities.  All self-insured health plans and TPAs should monitor this extremely critical Supreme Court decision on the BCBS appeals, in view of the fact that almost every TPA for self-insured health plans has engaged in successful overpayment recoupment and offsetting from healthcare providers in today’s multibillion-dollar overpayment recovery and offset industry.

For over 6 years, Avym Corp. has advocated for ERISA plan assets audit and embezzlement recovery education and consulting. Now with the Supreme Court’s guidance on ERISA anti-fraud protection, we are ready to assist all self-insured plans recover billions of dollars on behalf of hard-working Americans.

On May 14, 2014, in Hi-Lex Controls, Inc. v. Blue Cross Blue Shield of Michigan, 2014 WL 1910554, a federal appeals court (Sixth Cir. 2014) upheld a district court’s $6.1 million decision for Hi-Lex, a self-insured ERISA plan against BCBSM for violating ERISA in prohibited transactions and fiduciary fraud. Sixth Cir. concludes that (1) BCBSM served as a fiduciary for self-insured because it held or controlled plan assets and exercised authority over covered assets; (2) the Hi-Lex complaint was not time-barred because BCBSM’s actions triggered ERISA six-year fraud and concealment statute of limitations; and (3) BCBSM’s use of fees by self-paying it discretionarily charged for its own account is exactly the sort of self-dealing that ERISA prohibits fiduciaries from engaging in, according to the court document. (Sixth Circuit, Case Nos.: (13-1773, 13-1859), Decision Date: May 14, 2014).

The district court awarded Hi-Lex over $5 million in damages and prejudgment interest of almost $914,241. According to Hi-Lex’s allegations, BCBSM misrepresented and intentionally concealed these additional fees in contract documents and assured Hi-Lex that no fees were charged other than the administrative fee. Upon learning about the additional fees, Hi-Lex sued, claiming that BSBSM violated ERISA by engaging in self-dealing, according to the court document. (Sixth Circuit, Case Nos.: (13-1773, 13-1859), Decision Date: May 14, 2014).

In the Supreme Court, on Aug 12, 2014, BCBSM filed a Petition for a writ of certiorari, asking the high court to reverse a Sixth Circuit Court decision upholding a district court award of $6.1 million for a self-insured plan for fiduciary breach and ERISA fraud in concealing hidden fees as a TPA to Hi-Lex, a self-insured plan.

On Sep 15, 2014, an Amici Curiae Brief in support of BCBSM was filed by Blue Cross Blue Shield Association, America’s Health Insurance Plans, and Pharmaceutical Care Management Association, arguing “(I) the court of appeals’ decision creates uncertainty about when a third-party administrator is exercising control over plan assets”, and “(II) the court of appeals has created the specter that all third-party administrators could be deemed ERISA fiduciaries”, according to the court document.

BCBSA et al specifically argued: “In short, the determination as to whether an entity is an ERISA fiduciary is an important question with far-reaching ramifications that, in the context of the Sixth Circuit’s incorrect and aberrational decision, warrants this Court’s review. Review of that decision would ensure that the decision does not result in an ill-considered expansion of fiduciary litigation and liability for potentially thousands of ERISA plans covering millions of participants and billions in plan assets.” according to the court document. (Supreme Court Case No. 14-168, Title: Blue Cross Blue Shield of Michigan, Petitioner v. Hi-Lex Controls, Inc., et al., Docketed: Sep 15, 2014).

To find out more about Avym’s Overpayment Recoupment and Embezzlement Recovery Services or to contact us about educational programs please click here.  To Sign up for our newsletter and become an Avym Insider please click here.

UnitedHealthcare Class Action-UHC Sued for Overpayment Offsets in Violation of ERISA and for Misleading Patients and Plan Sponsors

On June 23, 2014, UnitedHealthcare was sued in a new provider class-action for its overpayment recoupment and offset practice, alleging ERISA violations and fraud. The new suit also alleges UHC engaged in withholding or offsetting new payments from providers while misinforming patients.

Overpayment offset and recoupments are Healthcare provider’s No. 1 denial; correspondingly, for self-insured health plans, the No. 1 hidden cost is overpayment recoupment and possible plan assets embezzlement. On June 23, 2014, UnitedHealthcare (UHC) was sued in a new provider class-action for its overpayment recoupment and offset practice for alleged ERISA violations and fiduciary fraud. The new ERISA class-action suit alleges:

  • UHC has been withholding or offsetting new payments in part or in whole from providers from one patient to satisfy another alleged overpayment in the past from other unidentified patients in violation of ERISA;
  • UHC then misleads patients and the plan sponsors as to payments made to the providers;
  • UHC has never complied with ERISA claims regulation when requesting alleged overpayments and offsetting new payments from other patients.

The new putative class on behalf of all similarly situated providers is seeking for ERISA benefits payments due, injunctive and declaratory relief, and ERISA notice and appeal rights.

“The No. 1 health care claim denial in the nation is payer overpayment recoupment and offset practice that does not comply with ERISA rules.  These offsets can go as far back as several years and affect all types of claims, potentially resulting in inevitable provider bankruptcy and subsequent patient bankruptcy”, according to Dr. Jin Zhou, president of ERISAclaim.com, a national expert on ERISA compliance and appeals.

The court case info: Peterson, D. C, et al v. UnitedHealth Group. et al, U.S. District Court U.S. District of Minnesota (DMN), Civil Docket For Case #: 0:14-cv-02101-PAM-SER, Filed 06/23/14.

Significantly, this ERISA putative provider class-action for the “Offset Class” was filed in the wake of and in accordance with a similar provider class-action filed recently in New Jersey for the “Recoupment Class”: Case Info: Premier Health Center, P.C., et al. v. UnitedHealth Group, et al., Case#: 2:11-cv-00425-ES-SCM, Filed 08/01/13, United States District Court for The District of New Jersey.

In last year’s court decision the court ruled against UHC in its overpayment recoupment practice:  “To be sure, as previously discussed, United’s recoupment procedures violate three specific ERISA regulations across the class.” according to the court document. “In 2011, United recovered approximately $430 million in overpayments to providers. 58% of the $430 million was recovered as a result of providers’ voluntarily sending a check to United, while 42% was recovered through offsets”, according to the court document. “However, they all violate ERISA in three respects. First, they fail to provide “[a] description of the plan’s review procedures and the time limits applicable to such procedures, including a statement of the claimant’s right to bring acivil action under section 502(a) of [ERISA] following an adverse benefit determination on review.” 29 C.F.R. § 2650.503-1(g)(1)(iv).25 Second, they fail to indicate that the provider, “upon request and free of charge, [will have] reasonable access to, and copies of, all documents, records, and other information relevant to the” overpayment determination. 29 C.F.R. §2650.503-1(h)(2)(ii). Third, they fail to “[p]rovide claimants at least 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determination.” 29 C.F.R. § 2650.503-1(h)(3)(i).” according to the court document.

In the new UHC provider class-action, healthcare providers alleged additional ERISA violations by UnitedHhealthcare Group for withholding and offsetting newly adjudicated claim payments from one patient to satisfy another alleged overpayment in the past from other unidentified patients which in some cases are members of a completely separate plan, in violation of ERISA.

Additionally, the new lawsuit alleges that UHC misled patients and the plan sponsors on patient EOB’s that indicated “payment made to provider”, when in truth and in fact no such payment was ever made to the providers, according to the Court Complaint.

In particular, the plaintiff Lutz Surgical Partners alleged the following:

“For example, ……Instead, United identified a different United Insured covered by a different United Plan who had been treated by Lutz on December 16, 2012. According to the PEOB, United caused that United Plan to pay Lutz $19,460.00 for this treatment which was now characterized by United as the “ORIGINAL OVERPAYMENT AMOUNT.” The PEOB then explained that the entire amount owed to Lutz for the services provided to the June 12, 2013 patient ($2,700.00) was being unilaterally offset against the prior alleged overpayment relating to the December 16, 2012 patient ($19,460.00), with the added explanation that “THIS REPRESENTS PREVIOUS BENEFITS THAT WERE PAID IN ERROR.” United therefore reported that the “TOTAL PAID TO THE PROVIDER” for services rendered to the June 12, 2013 patient was $0.00. In the “REMARKS” section of the PEOB, United stated: “The amount payable for this Explanation of Benefits has been used to reduce an overpayment made on the given claim(s). Please adjust your patient account balance accordingly.” according to the court document.

As more and more of these cases make their way through the courts, it is clear that the questionable or “legal gray area” of overpayment recoupment practices engaged in by many of the nation’s biggest insurance carriers, effectively triggers ERISA appeal rights.  Insurers and Health Plans will be forced to comply with all applicable federal laws, ERISA and PPACA claims regulations, as well as statutory fiduciary duties before recouping one single dollar. Providers or patients that face UHC or any payor recoupments or offsets would do well to understand the implications of these lawsuits as well as their rights under ERISA.

For more information click here.

BCBSM Overpayment ERISA Fraud – Self Insured Plan Award of $6.1 Million Upheld in Federal Appeals Court as BCBSM admits 83% of self-insured clients had no idea fees were being charged

Overpayment offset and recoupments are Healthcare provider’s No. 1 denial; correspondingly, for self-insured health plans, the No. 1 hidden cost is overpayment recoupment and possible plan assets embezzlement.

On May 14, 2014, a federal appeals court upheld a district court’s $6.1 million award for a self-insured ERISA plan against Blue Cross and Blue Shield of Michigan (BCBSM) for violating ERISA’s rules regarding prohibited transactions and fiduciary fraud.  The federal courts agreed that federal ERISA law prohibits BCBSM’s TPA self-dealing as an ERISA fiduciary by withholding all hidden fees or overpayment recovery, despite a prior state court decision upholding the enforceability of BCBSM’s TPA/ASO agreement.  This unprecedented decision will have tremendous repercussions for all self-insured health plan TPAs, as well as the Self-Insured Plans that employ them, in all overpayment recoupment actions.

In the first ruling of its kind, on behalf of all self-insured health plans, the federal courts ruled:

  1. ERISA prohibits BCBSM TPA self-dealing by retaining or withholding from plan assets regardless of BCBSM TPA/ASO agreement;
  2. ERISA prohibits BCBSM TPA fraudulent concealing or misrepresenting the plan claim hidden fees and TPA recoveries/savings,
  3. ERISA mandates BCBSM to refund self-insured plan assets for $6.1 million, according to the Sixth Circuit Court document.

(The court case info: Hi-Lex Controls, Inc. v. Blue Cross Blue Shield of Michigan, NOS. 13-1773/1859. United States Court of Appeals, Sixth Circuit, Decided and Filed: May 14, 2014).

In compliance with new federal appeals court decision for self-insured plans, Avym Corporation announces timely and critical solutions to the nation’s No. 1 health care cost driver for all self-insured plans: health claim overpayment recoupment/offset and plan assets embezzlement under ERISA.   The groundbreaking TPA/ASO auditing programs are unique and unlike any other traditional self insured health plan overpayment auditing programs and are designed to identify and recover alleged overpayments that have been recouped by the TPAs —but have not been disclosed, restored or refunded to the ERISA self insured plan assets as required under ERISA statutes and fiduciary responsibilities.   These federal court decisions are critical for all self-insured health plans to understand, in view of the fact that almost every TPA for self-insured health plans has engaged in successful overpayment recoupment and offsetting from healthcare providers in today’s multibillion-dollar overpayment market.

In the healthcare provider arena the No. 1 health care claim denial in the country today is the overpayment recoupment and claims-offset.  Correspondingly, for self-insured health plans, the No. 1 hidden cost is overpayment recoupment and plan assets embezzlement.

“This is the first appellate court decision to protect self-insured health plans and millions of hard-working American workers and their families,” says Dr. Jin Zhou, president of ERISAclaim.com, a national expert in ERISA compliance and overpayment recoupment plan assets recovery.

The Six Circuit Opinion: “SILER, Circuit Judge. The Hi-Lex corporation, on behalf of itself and the Hi-Lex Health & Welfare Plan, filed suit in 2011 alleging that Blue Cross Blue Shield of Michigan (BCBSM) breached its fiduciary duty under the Employee Retirement Income Security Act of 1974 (ERISA) by inflating hospital claims with hidden surcharges in order to retain additional administrative compensation. The district court granted summary judgment to Hi-Lex on the issue of whether BCBSM functioned as an ERISA fiduciary and whether BCBSM’s actions amounted to self-dealing. A bench trial followed in which the district court found that Hi-Lex’s claims were not time-barred and that BCBSM had violated ERISA’s general fiduciary obligations under 29 U.S.C. § 1104(a). The district court also awarded pre- and post-judgment interest. We AFFIRM.” according to the Sixth Circuit Court document

In particular, Sixth Circuit noted: “Furthermore, after a nine-day bench trial, the district court ruled that BCBSM had violated its general fiduciary duty under § 1104(a) and that Hi-Lex’s claims were not time-barred. The court awarded Hi-Lex $5,111,431 in damages and prejudgment interest in the amount of $914,241.” according to the Sixth Circuit Court document.

In finding against BCBSM for fiduciary fraud, the Sixth Circuit states: “BCBSM committed fraud by knowingly misrepresenting and omitting information about the Disputed Fees in contract documents. Specifically, the ASC, the Schedule As, the monthly claims reports, and the quarterly and annual settlements all misled Hi-Lex into believing that the disclosed administrative fees and charges were the only form of compensation that BCBSM retained for itself. BCBSM also “engaged in a course of conduct designed to conceal evidence of [its] alleged wrong-doing…… Finally, according to BCBSM’s own survey of its self-insured customers, a substantial majority – 83% – did not know the Disputed Fees were being charged.”, according to the Sixth Circuit Court document.

In concluding against BCBSM’s self-dealing and withholding, the Sixth Circuit concluded: “A fiduciary with respect to an ERISA plan “shall not deal with the assets of the plan in his own interest or for his own account.” 29 U.S.C. § 1106(b)(1). As interpreted by this court, that statute contains an “absolute bar against self dealing.” Brock v. Hendershott, 840 F.2d 339, 341 (6th Cir. 1988). Because this case involves the same ASC, same defendant, and same allegations, our decision in Pipefitters IV controls with respect to the § 1106(b)(1) claim. See Pipefitters IV, 722 F.3d at 868 (holding that BCBSM’s use of fees it discretionarily charged “for its own account” is “exactly the sort of self-dealing that ERISA prohibits fiduciaries from engaging in”).” according to the Sixth Circuit Court document.

To find out more about Avym Corporation’s Fiduciary Overpayment Recovery Specialist (FOR) and Fiduciary Overpayment Recovery Contractor (FORC) programs click here.

ERISA Court Fines United Healthcare $99,000 for Failing to Disclose Treatment Guidelines for 900 days!

A Federal Court in Tennessee orders United Healthcare of Tennessee, Inc (United) to pay $99,000 in ERISA penalties for failing to provide a patient with treatment guidelines for 900 days.  The $99,000 ERISA penalty is almost 3 times the amount of the medical claim benefits owed of $35,724.80

The US District Court Eastern District of Tennessee fined United Healthcare of Tennessee, Inc (United) $99,000 in ERISA penalties for failing to provide a patient plaintiff with United’s Treatment Guidelines (Medical Policy) for 900 days.  The order came after the court had ordered United to pay $35,724.80 plus pre-judgment interest for United’s medical necessity denials. The court also ordered United to pay Plaintiff attorney fees.

The court’s ERISA United decision provides very powerful protection for all patients and providers with a possible $110 per-day statutory penalty for all medical necessity denials. PPACA has adopted ERISA claim regulations for both ERISA plans and non-ERISA plans.  http://www.dol.gov/ebsa/healthreform/#internalclaimsandappeals

As a result of this court decision, both participating and non-participating hospitals, ASC’s and all providers should seek ERISA compliance and medical necessity appeals training in order to properly appeal all medical necessity denials using this court guidance in compliance with ERISA and PPACA regulations.

The court case info: Butler v. United Healthcare of Tennessee, United States District Court Eastern District Of Tennessee At Knoxville, No. 3:07-CV-465, Filed 09/30/13.

Ms. Butler’s (Plaintiff) insurer, United Healthcare, denied the claim on the basis that the service was not medically necessary. United had relied upon a physician reviewer opinion provided by a third-party service, Medical Review Institute of America.  The case was remanded twice and dragged into its fifth year of litigation before the courts made their final ruling.

According to the court, “United’s careless handling of Ms. Butler’s claim, and its repeated denials, is confounding.”  “[The] court believes that United’s handling of Ms. Butler’s claim was a result of a bureaucratic, perfunctory, and scattered process that was a product of United’s underlying conflict of interest”

The court goes on to say, “ERISA authorizes the court to impose statutory penalties in certain circumstances. Here, an administrator who fails to furnish, upon a participant’s request, any internal rule, guideline, or similar criterion that was relied upon to make the adverse determination may be liable for up to $110 per violation (i.e. per day). 29 U.S.C. § 1132(c)(1)(B); 29 C.F.R. § 2575.502c-1 (2013). The calculation of the penalty begins thirty days after the participant’s request for such information.”

The court ordered: “United was required to provide a copy of the Guidelines upon request. Mr. Butler requested those Guidelines on February 10, 2006 (see AR 164), but he did not receive those Guidelines until July 30, 2008, when United filed the administrative record. That filing came 900 days after Mr. Butler formally requested the Guidelines. Given the length of time during which the Guidelines were not disclosed, and the negative effect such non-disclosure had on Mr. Butler to present his appeal, the court awards the maximum penalty for each day of delay, which amounts to $99,000.00.” according to the court document.

Medicare Anti-fraud Recovery Reaches $19 Billion; How Much for Private Self-Insured Plans? Is your third-party administrator holding out on you?

The Department of Health and Human Services and The Department of Justice Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2012

Approximately 82.1% of large health plans (>500) are self-insured. 

With possibly more than $19 billion in anti-fraud and overpayment recovery by TPAs from healthcare providers in the private sector, how much has your self-insured plan received from your TPA’s Overpayment Recoupments?

On February 11, 2013, HHS and DOJ announced record-breaking anti-fraud recoveries of $4.2 billion for 2012, and $14.9 billion over the past four years.  Additionally, CMS has recovered $3.16 Billion in separate non-fraud overpayment recovery over the past three years.

http://www.hhs.gov/news/press/2013pres/02/20130211a.html

https://oig.hhs.gov/reports-and-publications/hcfac/index.asp

http://aspe.hhs.gov/health/reports/2011/LGHPstudy/index.shtml

“If Medicare contractors recovered $19 billion in anti-fraud and overpayment recoupments and failed or refused to return that $19 billion to Medicare and Medicaid, would those contractors be allowed to keep that money?  Likewise shouldn’t all private self-insured plans expect to reap a windfall from years of TPA antifraud and overpayment recoupments?” says Dr. Jin Zhou, president of ERISAclaim.com, a national expert in ERISA and PPACA compliance, and a well-recognized expert in provider overpayment appeals and ERISA provider class action.

The question is very simple: with possibly more than $19 billion in anti-fraud and overpayment recovery from healthcare providers in the private sector, how much has your self-insured plan received from your TPA’s Overpayment Recoupments?

Avym Corporation (Avym) announces 2013 Fiduciary Overpayment Recovery programs for private self-insured health plans.  In 2011 private health insurance funded approximately 33% and Medicare funded approximately 21% of the $2.7 trillion national healthcare expenditure.  Approximately 82.1% of all large health plans (>500) are self-insured.  Avym’s innovative new programs consist of:

  • The Fiduciary Overpayment Recovery Specialists (FOR) training program which is designed for private self-insured plans.
  • The Fiduciary Overpayment Recovery Contractor (FORC) program which is designed to create partnership networks nationwide to immediately offer FOR programs to self-insured plans.

These groundbreaking programs are unique and unlike any other traditional health plan overpayment auditing programs and are designed to recover alleged overpayments, regardless of fraud allegations, that have been completely recouped by the TPA’s for whatever reason but have not been restored or refunded to the ERISA plan assets as required under ERISA statutes and fiduciary responsibilities.

Most recent federal anti-fraud investigations, indictments, settlements and court orders result in adverse outcomes for providers, typically as payments and penalties to Medicare and Medicaid as well as private health plans.   Most private health plan TPA’s overpayment recoupment practices are not as transparent or public as the Medicare or Medicaid programs and typically involve automatic and silent recoupment from providers on both previous patients and new patients.

http://www.hhs.gov/news/press/2012pres/07/20120726a.html

https://oig.hhs.gov/fraud/enforcement/criminal/

It is estimated by industry experts $19 billion may pale in comparison to what may have been recovered in the private sector over the past three or four years.  Alleged anti-fraud settlements with sweeping federal and state antifraud enforcement, unreported nontransparent automatic recoupment from providers and silent offsetting or withholding are all contributing factors.  The Institute of Medicine claims that “about 30 percent of health spending in 2009 — roughly $750 billion — was wasted on unnecessary services, excessive administrative costs, fraud, and other problems”. http://www8.nationalacademies.org/onpinews/newsitem.aspx?recordid=13444

The following OIG overpayment audit reports for governmental programs were instrumental in the FOR programs design and launch:

OIG of U. S. Office of Personnel Management: “Audit of Bluecross Blue Shield Association Washington, DC and Chicago, Illinois”, March 6, 2012,

“The Association’s FEP Special Investigations Unit (SIU) is not in compliance with Contract CS 1039 and the FEHBP Carrier Letters issued by the Office of Personnel Management (OPM) related to F&A Programs and notifying OPM’s Office of the Inspector General of F&A cases in the FEHBP.” http://www.opm.gov/our-inspector-general/reports/2012/final-report-no-1a-10-91-11-030-bcbs-association-in-washington-dc-and-chicago-illinoi-_redacted.pdf

HHS OIG Report: “Delaware Did Not Comply With Federal Requirements To Report All Medicaid Overpayment Collections”, 06/22/2012

“We found that Delaware did not comply with Federal requirements to report all Medicaid overpayment collections. Of the $16.29 million Medicaid overpayments collected, the State failed to report $16.27 million ($10 million Federal share). State officials said that they believed the overpayments had been netted out of reported Medicaid expenditures but did not provide support for such an adjustment.” https://oig.hhs.gov/oas/reports/region3/31100203.asp

DOL Fiduciary Compliance Guidance: “Meeting Your Fiduciary Responsibilities:

“With these fiduciary responsibilities, there is also potential liability. Fiduciaries who do not follow the basic standards of conduct may be personally liable to restore any losses to the plan, or to restore any profits made through improper use of the plan’s assets resulting from their actions.” http://www.dol.gov/ebsa/publications/fiduciaryresponsibility.html

Self-Insured Plan TPA recoupments, which can reach 30% of annual plan healthcare expenses, must be refunded to self-insured plans in a timely manner.  Otherwise plan assets could be exposed to huge losses and Plan Administrators can be exposed to incredible fiduciary liability.

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 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.

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

PPACA Protects 35,000 Soon to be Ex-Aetna PPO Doctors in California Managed Care Lawsuit

Aetna’s war against the California Medical Association (CMA) for patient’s right to choose provider versus Aetna’s right to save money has spurred the 10th Patient Protection and Affordable Care Act (PPACA) Claims Specialists Certification Program.

The timing of the PPACA Program, scheduled for Sept 15, 2012 is appropriate in light of recent CMA Press and LA Times Report, 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 are designed to provide 35,000 California doctors with compliant solutions to patient’s right to choose and protections under the new federal health reform law.  On June 28, 2012, the Supreme Court upheld PPACA’s constitutionality.

Avym Corporation’s 10th Ex-PPO Program is a comprehensive PPACA & ERISA compliance program covering PPACA and ERISA patient protections, appeals regulations and Corporate Compliance – Fraud and Abuse Prevention in order to avoid allegations and litigations currently faced by many PPO and Ex-PPO providers.  The two-day Ex-PPO program is a turn-key operation in education, with one day devoted to PPACA & ERISA appeals and the other day focusing on fraud and abuse prevention.

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

CMA Letter to Aetna

CMA Letter to Aetna Lawyers

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.”
http://www.latimes.com/business/la-fi-aetna-doctors-feud-20120830,0,7996610.story

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

“While we cannot pass any judgment on the merits of the court allegations from Aetna or the CMA, as that judgment is entrusted to the Courts, we can provide PPACA compliant solutions for providers to fully and properly disclose any self-referrals and/or 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.”, said Mark Flores, PPACA ERISA Claim Specialist, co-founder of AVYM Corporation in Los Angeles, California.

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”.  http://www.ama-assn.org/amednews/2012/06/25/bise0626.htm

“About 77% of insured Americans pay higher premiums for first-class out-of-network coverage, but only about less than 5% of out-of-network claims are filed each year,” says Vincent Flores, a certified PPACA and PPACA ERISA Claim Specialist, co-founder of AVYM Corporation in Los Angeles, California. http://avym.com/

The 10th PPACA Claims Appeals Specialists Certification Programs were announced today in Los Angeles by AVYM, in order to assist 35,000 soon to be Ex-PPO CMA member doctors from Aetna PPO Networks.  AVYM’s 10th PPACA Ex-PPO Program will cover the 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 67):   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 and 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 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.