http://www.hhs.gov/healthcare/facts/widgets/index.html

With enrollment deadlines approaching, California officials, insurers and agents are opening stores in outlets across the state to sign up individuals for Obamacare policies.

Certified counselor Helen Lee, right, signs up a woman for health coverage at a Covered California exchange office in the Baldwin Hills Crenshaw mall. (Anne Cusack, Los Angeles Times / November 27, 2013)

By Chad TerhuneNovember 27, 2013, 5:17 p.m.

As shoppers hunt for holiday bargains this season, they may find something unusual for sale at the mall: Obamacare.

With enrollment deadlines looming, California officials, insurance companies and agents are staking out retail space to sign up thousands of people as part of the Affordable Care Act. These sales tactics reflect how dramatically the healthcare law is changing the insurance industry.

Until recently, most health insurance companies and agents didn’t put much time into selling policies to individuals and focused more on catering to employers and large groups in the workplace. But the health insurance mandate and billions of dollars in federal premium subsidies have made individual policies a far more attractive market.

California’s health insurance exchange and other government-run marketplaces are rushing to sign up people by Dec. 23, the deadline to have coverage in effect Jan. 1. Open enrollment lasts until March 31.

A state lawmaker and union organizers last week opened a mall store in a predominantly African American area of Los Angeles. In Orange County, insurance agents are signing up dozens of people each week at Laguna Hills Mall, and healthcare giant Kaiser Permanente has rented five retail locations in Northern California to sell exchange policies.

The Covered California exchange has posted solid enrollment since opening Oct. 1, primarily through its website and call centers. It has signed up nearly 80,000 people in private health plans through Nov. 19 and an additional 135,000 people have applied for Medi-Cal, the state’s Medicaid program for the poor.

But the exchange estimates that about 80% of people will want in-person help to figure out their insurance options. Rather than set up storefronts itself, Covered California has focused more on training people who then go out to farmers markets and health fairs to promote the exchange and do enrollment.

Some consumer advocates welcome the increased retail exposure, but they worry that stores run by insurers or agents might push certain health plans and leave out other choices on the exchange.

“Having a lot of venues where people are running errands is a good thing,” said Betsy Imholz, special projects director at Consumers Union. “But we want to avoid inappropriate steering. There are upsides and downsides to this.”

State Sen. Holly Mitchell (D-Los Angeles) said she pushed for a Covered California store at the Baldwin Hills Crenshaw mall because many lower-income people who stand to benefit most from the healthcare law aren’t likely to click on a website.

“There are still people who don’t have access online,” Mitchell said. “We want to bring health insurance to where people are naturally, and the clock is ticking on the enrollment window.”

Billboards for Covered California surround the Baldwin Hills mall, beckoning people to “health insurance made affordable.” The small store is on the mall’s second floor, across from a nail salon and a short stroll from Macy’s and Foot Locker.

It has a counter stacked full of insurance brochures and a small table where state certified enrollment counselors use a laptop to answer people’s questions and help them get coverage.

Capri Capital Partners, the mall’s Chicago owner, said it donated the space until open enrollment ends March 31. The location is open seven days a week with afternoon and evening hours.

Brenda Hardson, 51, was handed a brochure about the mall store recently and came back with her uninsured daughter, Rickesha Morris. The 31-year-old was recently laid off from her job and she sat down with an enrollment worker to review her options.

“It’s always better to speak with someone face to face,” Hardson said. “The website only answers general questions.”

In Northern California, Kaiser has hired 40 people to run its five stores in San Jose, Sacramento, Modesto and Fresno. A sixth location is planned for Stockton in December.

The Oakland nonprofit said it got 10,000 visitors to two mall kiosks it opened last year, and it drew lessons from that experience.

“We know people have a lot of questions about healthcare reform, how to get coverage and what kind of financial assistance might be available to them,” said Wade Overgaard, a senior vice president at Kaiser Permanente.

Kaiser says its store workers are certified by the state and will enroll people in Kaiser policies as well as competitors’ health plans.

Inside Laguna Hills Mall, the Insurance Resource Center is signing up more than 100 people per week as part of the healthcare law rollout. Gary Mann, a senior partner with Nationwide Senior Plans, said he and a partner opened the 3,000-square-foot store in mid-October.

Eight agents, all trained and authorized to enroll people by the state exchange, cover the store seven days a week. It features signs for Covered California and major insurers, such as Anthem Blue Cross.

The agents don’t charge people to answer their questions or enroll them in a health plan or Medi-Cal. Rather, the agents get paid commissions by the insurance companies.

Mann said the store is seeing an increase in traffic from policyholders who are having their existing coverage canceled Dec. 31 because it doesn’t meet all the requirements of the Affordable Care Act.

Covered California rejected President Obama‘s recent call to extend those canceled plans for another year, and an estimated 1 million Californians are losing their current policies.

That has angered many consumers, and Mann said others who oppose the healthcare law vent at his store.

“We get some hostile people and they shout at us,” he said.

His biggest concern, however, is people putting off their insurance shopping until the last minute. “People procrastinate,” Mann said, “and if everyone jumps on at the end, it will really test the system.”

chad.terhune@latimes.com

http://www.latimes.com/business/la-fi-exchange-retail-20131128,0,380583.story#ixzz2lxi29kD9

Washington (CNN) — The high-stakes fight over implementing parts of the troubled health care reform law will move to the U.S. Supreme Court in coming months, in a dispute involving coverage for contraceptives and religious liberty.

The justices agreed on Tuesday to review provisions in the Affordable Care Act requiring employers of a certain size to offer insurance coverage for birth control and other reproductive health services without a co-pay.

At issue is whether private companies can refuse to do so on the claim it violates their religious beliefs.

Oral arguments will likely be held in March with a ruling by late June.

Nearly 50 pending lawsuits have been filed in federal court from various corporations challenging the birth control coverage benefits in the “Obamacare” law championed by President Barack Obama, which has come in for fierce political criticism over its rocky public introduction.

The high court last year narrowly upheld the key funding provision of the health care law, a blockbuster ruling affirming that most Americans would be required to purchase insurance or pay a financial penalty — the so-called “individual mandate.”

The constitutional debate now shifts to the separate employer mandates and whether corporations themselves enjoy the same First Amendment rights as individuals.

Three federal appeals courts around the country have struck down the contraception coverage rule, while two other appeals courts have upheld it. That “circuit split” made a Supreme Court review more likely.

The Supreme Court agreed to hear two cases involving for-profit corporations. Among the plaintiffs is Hobby Lobby, Inc. a nationwide chain of about 500 arts and crafts stores.

Hobby Lobby finds way around $1.3-million-a-day Obamacare hit – for now

David Green and his family are the owners and say their Christian beliefs clash with parts of the law’s mandates for comprehensive coverage.

They say some of the drugs that would be provided prevent human embryos from being implanted in a woman’s womb, which the Greens equate to abortion.

The privately held company does not object to funding other forms of contraception — such as condoms and diaphragms — for their roughly 13,000 employees, which Hobby Lobby says represent a variety of faiths.

Companies that refuse to provide the coverage could be fined up to $1.3 million daily.

Kyle Duncan, general counsel of the Becket Fund for Religious Liberty and lead lawyer for Hobby Lobby, called the Supreme Court decision to hear the case a “major step” for the Greens and their business, and “an important fight for Americans’ religious liberty.”

Opinion: Religious liberty is for people, not corporations

The White House said on Tuesday that it believes a requirement on contraceptives is “lawful and essential to women’s health.”

The White House added that it is “confident the Supreme Court will agree.”

The Obama administration has defended the law and federal officials say they have already created rules exempting certain nonprofits and religiously affiliated organizations from the contraceptives requirements. In those cases, women would receive coverage from another company at no cost.

The Supreme Court was asked to take up the issue by a private Christian university in Virginia but the court, without explanation, decided not to hear that appeal.

The law’s supporters say it does not require individual company owners to personally provide coverage they might object, but instead places that responsibility on the corporate entity.

A key issue for the justices will be interpreting the 1993 federal law known as the Religious Freedom Restoration Act. Can companies, churches, and universities be included, or do the protections apply only to “persons?”

The botched rollout of HealthCare.gov, the federal Obamacare website, has become a political flashpoint along with other issues that Republicans say proves the law is unworkable.

WH: Obamacare website ‘on track’ to meet Nov. 30 goal

The cases accepted were Sebelius v. Hobby Lobby Stores, Inc. (13-354); and Conestoga Wood Specialties Corp. v. Sebelius (13-356).

Church and state, executive power on Supreme Court docket

http://www.cnn.com/2013/11/26/politics/obamacare-court/

On November 7, 2013, the United States District Court for the Northern District of Illinois granted in Summary Judgment against BCBS in an overpayment ERISA class action for certain plaintiff providers. The court clarified among other issues that:

• Providers are entitled to sue under ERISA;
• Certain BCBS entities completely violated ERISA;
• These providers are not liable to BCBS overpayment claims;

The federal court summary judgment decisions were made in the wake of the court’s prior decision on October 12, 2012, denying BCBS motion to dismiss and in favoring of the provider ERISA arguments.  The suit dates to 2009.

In response to this landmark court decision, Avym Corporation announces new webinars and advanced ERISA claim specialist programs to demystify this federal court decision on the nation’s No. 1 health care claim denial issue: overpayment demand recoupments and offsetting.  This training will also examine how to correctly appeal every overpayment demand with a valid ERISA assignment and in complete compliance with ERISA & PPACA claim regulations.

Provider overpayment recoupment demands or offsets have become the number one claim denial in the nation.  Industry estimates put the offset amounts in the hundreds of millions annually.  This court case provides clarity with respect to the overpayment recoupment practices engaged in by many of the nation’s biggest insurance carriers.  The court has effectively answered the central question of whether insured’s overpayment demands trigger ERISA appeal rights with a resounding yes as 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 that face BCBS or any payor recoupments or offsets would do well to understand the implications of this court ruling as well as their rights under ERISA.

According to providers complaints BCBS insurers made reimbursement payments for medical services rendered.  A short time after BCBS came back to those providers and said the payments were made in error for uncovered services. If the providers failed to submit to the demands and the money wasn’t returned, BCBS allegedly withheld funds for services rendered to other BCBS members that hadn’t yet been reimbursed:

“Plaintiffs allege that defendants improperly took money belonging to plaintiffs. They allege that they provided medical services to BCBS insureds. Defendants would initially reimburse plaintiffs for these services. Sometime afterward, plaintiffs allege, defendants would make a false or fraudulent determination that the payments had been made in error. Defendants then would demand that plaintiffs repay the supposedly overpaid amounts immediately. If plaintiffs refused to do so, defendants would forcibly recoup the amounts they sought by withholding payment on other, unrelated claims for services plaintiffs provided to other BCBS insureds.”

All of this was allegedly done without any explanation as to why or how BCBS determined the errors:

“Plaintiffs allege further that when defendants made these repayment demands, they typically did not provide adequate information regarding the reason for the demands or procedures for challenging the demands. Plaintiffs allege that defendants sometimes failed to offer any appeal process at all. When an appeal process was available, plaintiffs allege, defendants refused to provide details about which patients, claims, and plans were claimed to be the subject of overpayment or “effectively ignored” Case: 1:09-cv-05619 Document #: 846 Filed: 11/07/13 Page 2 of 40 PageID #:368953 plaintiffs’ appeals. Fourth Am. Compl. ¶ 18. Plaintiffs contend that this conduct deprived them of their right to a “full and fair review” under ERISA. 29 U.S.C. § 1133.”

“This federal court decision doesn’t mean that no insurance company can ask any providers for any money back as overpayment, it simply means that no insurance company can do so without complying with ERISA, which governs and regulates medical claim disputes for all private healthcare plans,” cautions by Dr. Jin Zhou, a national expert in ERISA & PPACA compliance and appeals.

Plaintiffs’ attorney D. Brian Hufford of Pomerantz Grossman Hufford Dahlstrom & Gross LLP praised the ruling: “The decision found for us on the merits of our claim that an insurer must comply with ERISA when seeking to recover from providers previously paid health care benefits,” he said. “Given the hundreds of millions of dollars recouped by insurers every year, this decision could have widespread implications.”

In denying motion for summary judgment for BCBS entities and granting motion for summary judgment for certain plaintiff providers, among other things, the federal court makes the following conclusion:

“Conclusion:    For the foregoing reasons, the Court grants plaintiff Reno’s motion for summary judgment [docket no. 793] on the question of liability as to defendant Anthem Health Plans of Virginia, Inc. but denies the motion with regard to defendant WellPoint, Inc. The Court grants plaintiffs Barnard & Wahner’s motion for summary judgment [docket no. 795] as to liability on their claim against defendant Independence Blue Cross for improper denial of benefits but denies in part plaintiffs’ motion on their claim that Independence denied them the appropriate notice and appeal rights, while making findings in plaintiffs’ favor on certain points pursuant to Rule 56(g). At tomorrow’s status hearing, counsel should be prepared to discuss what further proceedings are required on the claims of these plaintiffs.” according to court records

In particular, the court makes the following legal reasoning and discussion in part:

Reno’s summary judgment motion against Anthem and WellPoint:

“1. Standing: ……The Court concludes that Reno is a beneficiary for purposes of ERISA and thus has standing, conferred on him by section 1132, to bring his claims.” according to the court records.

“2. Denial of notice and appeal rights: ……The Court therefore concludes that Reno is entitled to summary judgment as to liability on his claim that Anthem denied him the notice and appeal rights to which he was entitled under ERISA. The only matter that remains for determination on that claim is the appropriate relief.” according to the court records.

“3. Denial of benefits: …… The Court therefore grants summary judgment to Reno against Anthem as to liability on this claim as well.” according to the court records.

Case Info: Pennsylvania Chiropractic Association, et al. vs Blue Cross Blue Shield Association, et al., Case No.: 1:09-cv-05619, Document #: 846, Filed: 11/07/13, in the United States District Court for the Northern District of Illinois Eastern Division

As part of best practices for reimbursement purposes, we further advocate for ERISA compliance by every healthcare provider to appeal every overpayment denial or offset, regardless whether a plan or provider may be right or wrong on its overpayment determination, as specifically advised by DOL, federal agency in charge of ERISA interpretation and enforcement:

DOL Tri3 Enterprises Amicus Brief, supporting plaintiff-appellant, No. 12-2308, File on 11/30/2012, In the United States Court of Appeals for the Third Circuit

“The crux of the question at issue here is not whether the plaintiff or the defendant is correct in their views of the plan terms, but whether Aetna must comply with the procedures mandated by ERISA section 503 and its accompanying regulations in rendering a determination based on a plan interpretation that is adverse to the plan participants and beneficiaries. Under the statute and regulations, the beneficiary or participant is entitled to a claims procedure that “afford[s] a reasonable opportunity . . . for a full and fair review by the appropriate named fiduciary of [a] decision denying [a] claim,” …… In either event, Tri3 is entitled to insist upon its assigned right to challenge the allegedly wrongful decision to deny benefits through a process that complies with the claims regulation.”   http://www.dol.gov/sol/media/briefs/tri3-enterprises(A)-11-30-2012.htm#.UMfi5z9MHFo

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.

A recent case may help out of network providers, which have complete valid ERISA assignments regarding appeal and reimbursement rights, receive checks directly from insurers.

For the first time federal courts have rendered the clearest answers to date: managed care network participation is immaterial, ERISA assignment is the critical controlling factor to health-care benefits reimbursement.  On August 5, 2013, a federal court concluded that Blue Cross Blue Shield of Michigan (BCBSMI) must directly pay an out-of-network provider with a valid ERISA assignment, even after his patients were already paid, and that the mistaken payments made to patients did not extinguish the BCBSMI obligation to pay the provider under ERISA.

In this case, the provider (Metcalf) is a physician who had assignments from patients to receive benefits from their ERISA governed plan for services rendered, the ERISA plan (BCBSMI) paid benefits for provider’s medical services after being put on notice of the medical provider’s assignment but the benefits were mistakenly sent to the patient. The provider sued to compel the BCBSMI to pay him the benefits as assignee of his patients even though BCBSMI had already paid the patients the benefits. BCBSMI argued that because they mistakenly paid the patients absolved them from any liability to the provider as assignee because, they reasoned, the benefits had been paid already and there were no benefits due. In addition the BCBSMI argued that provider, as assignee, only stands in the shoes of the plan participants and the plan participants had already been paid.

The opinion is a significant holding that will be useful to providers with complete valid ERISA assignments regarding appeal and reimbursement rights. The court concluded:

1. BCBSMI must directly pay an out-of-network provider with a valid complete ERISA assignment, even after his patients were already paid
2. The mistaken payments sent to patients did not extinguish BCBSMI obligation to pay the provider under ERISA
3. The provider’s network participation is immaterial to the plan’s obligation to provide EOB disclosures, ERISA full and fair reviews and to make payment directly to the provider under ERISA
4. The provider’s ERISA assignment was valid, thus entitling him to sue BCBSMI for ERISA SPD statutory penalties, (although unavailable in this case).

According to the court document, BCBSMI refused to recognize the ERISA complete assignment from an out-of-network provider, refused to provide the provider with benefits EOB, refused to consider any appeals filed by the provider, and made benefits payments to the patients directly.

Both parties filed for summary judgment on these claims.

Case info: Robert Metcalf, v. Blue Cross Blue Shield of Michigan; DaimlerChrysler North America; and Daimler Trucks N.A. LLC UAW Health Benefits Plan, Case 3:11-cv-01305-ST, United States District Court District of Oregon, Portland Division, Decided 08/05113.

Among other things, of critical significance for out-of-network provider appeals and litigation, the Court concludes the following legal points:

ERISA assignment and notice, rather PPO network participation, entitled a provider to direct reimbursement:

“As discussed elsewhere in this Opinion, defendants were on notice of the assignments entitling Metcalf to direct payment of the benefits due his patients under the Plan, irrespective of whether he was a Network Provider or Nonparticipating Provider.” according to the court document.

Even if BCBSMI already paid patients of an out-of-network provider, BCBSMI must pay again directly to the out-of-network provider:

“Thus, this court concludes that under the state law governing assignments, the debt is not discharged by the debtor who pays the assignor after receiving notice of the assignment. Even though the Plan paid benefits to the participants, its duty to pay benefits to their assignee (Metcalf) was not discharged. As a result, Metcalf, as the assignee, has a claim against the Plan for benefits mistakenly paid to each of his patients-assignors after BCBSM received notice of the assignment……That relief is available under ERISA since payment by the Plan to the patients-assignors did not extinguish the obligation to pay benefits.” according to the court document.

BCBSMI asserted that even though the assignments were valid Health care providers, such as Metcalf, are not participants or beneficiaries and, therefore, lack independent standing to sue under ERISA.

“the Ninth Circuit barred ERISA claims by medical providers, based upon assignments from their patients of the right to payment of benefits, against health care plans to recover additional payments based on their separate provider contracts with the plans. Unlike those cases, Metcalf does not seek the payment of more money from the Plan based upon an independent obligation different than money owed to the participants under the Plan. Here pursuant to the terms of the AOBs, Metcalf is suing to recover “all insurance benefits, if any, otherwise payable to [the plan participant] for services rendered” and nothing more. Therefore, Metcalf has derivative standing under ERISA as an assignee to assert the claims of his patients-assignors to recover benefits due under the Plan under 29 USC § 1132(a)(2). Although he stands in the shoes of his patients-assignors, Metcalf contends that his status as an assignee permits him to recover any benefits owed and not paid directly to him, but instead paid to his patients-assignors. This appears to be a novel issue not yet addressed by any court.” according to the court document.

After the court orders BCBSMI to pay the provider directly again, and court finds the provider’s ERISA assignment is valid and entitles the provider to sue the plan for the ERISA SPD statutory penalties, but the court explains why such statutory penalties are not available in this case:

“Given this court’s conclusion that he is entitled to payment of those benefits, the imposition of penalties serves no purpose other than as an excessive punishment for defendants failing to promptly correct their mistake of law. Accordingly, even if statutory penalties were available, this court would exercise its discretion against awarding them in this case.” according to the court document.

Out of Network Providers of all types would be well advised to obtain valid complete ERISA assignments from any and all patients.  Providers should also keep a copy of this opinion for future use when disputes arise between themselves and insurers specifically when insurers have sent reimbursement checks directly to patients after being put on notice of the provider’s valid complete ERISA assignment.

The 7^th circuit panel, citing a recent Supreme Court decision, seems to have established new insurance verification laws under ERISA, in a case where a patient is entitled to a $77,974 monetary damage award after her health plan falsely verified coverage for a procedure when none existed thereby creating an ERISA fiduciary breach, holding the plan fiduciary liable for money damages as an equitable relief under ERISA, by failing to provide accurate and complete coverage information and/or means to obtain authoritative and binding information specifically requested by a patient or provider prior to the treatment.

Case info: Deborah Kenseth v. Dean Health Plan, Inc., In the United States Court of Appeals for the Seventh Circuit, Case No. 11-1560, Decided June 13, 2013.

This is the first court decision in the 37 year history of ERISA that provides money damage protection against a plan’s false coverage verification loophole in violation of ERISA, even if no true coverage existed under the plan. The court decisions have profoundly changed the entire healthcare industry compliance and litigation landscape with respect to insurance coverage verification and/or precertification for both in-network and out-of-network patients, providers, health plans and managed care TPA’s.

The facts of the case are commonplace in the healthcare industry: A doctor recommended gastric bypass surgery for Kenseth in 2005 to deal with complications from a previous surgery in 1987. At the time of the gastric bypass surgery, Kenseth worked for Highsmith Inc., which used Dean Health to provide health insurance benefits to its workers. She called a Dean Health customer service representative to get pre-approval for the surgery and was told that her surgery would be covered and all she had to pay was a $300 deductible. Kenseth underwent the surgery which cost close to $78,000 in medical bills. The claim was then submitted to the health insurer for payment. One day after her surgery, the plan decided to deny coverage for the surgery and all associated services based on the exclusion for services related to a non-covered benefit or service, namely, surgical treatment of morbid obesity, according to the court documents. Kenseth eventually got a bill from her provider for nearly $78,000.

After exhausting all her appeal remedies, she sued the plan in federal court for ERISA fiduciary breach and reimbursement of surgical costs of $77,974. The district court twice ruled against her and she twice appealed to the 7th Cir. Court, losing the first one but winning the second appeal, due to a recent Supreme Court decision in Cigna Corp. v. Amara, 131 S. Ct. 1866 (2011, Case No. 09–804), clarifying the relief available for a breach of fiduciary duty in an action under the ERISA, according to the court document.

The 7th Cir. Court concludes: “Cigna substantially changes our understanding of the equitable relief available under section 1132(a)(3). Kenseth has argued for make-whole relief in the form of monetary compensation for a breach of fiduciary duty from the start of this litigation. We now know that, in appropriate circumstances, that relief is available under section 1132(a)(3). See Cigna, 131 S. Ct. at 1881-82”, according to the court document.

In addition to the new money damage remedies available under ERISA, the 7th Cir. Court also clarifies the plan’s fiduciary duties or obligations to provide “accurate and complete” information and documents when a patient or provider inquires about insurance coverage, regardless of in-network or out-of-network provider status.

The 7th Cir. Court clarifies: “we have previously held that an insurer has an affirmative obligation to provide accurate and complete information when a beneficiary inquires about her insurance coverage…….The most important way in which the fiduciary complies with its duty of care is to provide accurate and complete written explanations of the benefits available to plan participants and beneficiaries……But if the documents are ambiguous or incomplete on a recurring topic, a fiduciary may be liable for mistakes that representatives make in answering questions on that subject”, according to the court document.

Avym Corporation offers new seminars to examine why and how these new court decisions will immediately and profoundly change the entire healthcare industry’s insurance coverage verification and/or precertification process for both in-network and out-of-network patients, providers, health plans and managed care TPA’s; how health plans should comply with ERISA in order to avoid money damage ERISA surcharge; and how to obtain money damage reimbursement even without a plan coverage if a plan breached its ERISA fiduciary duties and harmed a patient, as prescribed by the Supreme Court.

To find out more about PPACA Claims and Appeals Compliance Services from AVYM please click here.

By Linda Stern, Reuters

by Jeffrey Young, The Huffington Post

by Kathleen Sebelius, The White House Blog