Category Press Releases

Avym, along with the State of New Jersey, acting through the New Jersey Attorney General Matthew J. Platkin, announced today that Horizon Healthcare Services, Inc. has agreed to pay $100 million to settle a lawsuit McKool Smith filed in 2021 on behalf of several whistleblowers, including Avym principals and founders Mark Flores, and Vince Flores.

The suit, brought under the qui tam provisions of the Federal False Claims Act (FCA) and the New Jersey False Claims Act, alleges that Horizon defrauded the New Jersey State Health Benefits Program and the State Employee Health Benefit Plan (“State Benefit Plans”).

The allegations relate to Horizon’s role administering the medical benefits of hundreds of thousands of New Jersey government employees. Horizon submitted false funding claims to the State for years, costing taxpayers hundreds of millions of dollars. 

This case involved allegations of a multi-year scheme by Horizon to take New Jersey taxpayer money from State employee and school health benefit plans.

Mark Flores, a nationally recognized health benefits consultant, expressed his thanks to the Office of the Attorney General.  “We would like to thank Attorney General Platkin and the devoted lawyers in the Government and Healthcare Fraud Unit for paying attention to this important issue, for investigating our allegations, and pursuing the claims to protect State Health Plan members and New Jersey taxpayers.”  Vince Flores, a health benefits consultant, followed, “We hope this settlement will cause Horizon and other health insurers to examine how they administer self-funded plans.”

All “Relators” include Mark Flores, Vince Flores, Chris Deacon, Kevin Lyons, Pat Colligan & Marc Kovar

Link to Complaint: https://www.njoag.gov/wp-content/uploads/2025/11/2025-1114_NJ-US-ex-rel-Lyon-v-Horizon_Complaint-in-Intervention.pdf

Link to Settlement Agreement: https://www.njoag.gov/wp-content/uploads/2025/11/2025-1114_NJ-ex-rel-Lyons-v-Horizon_Executed-Settlement-Agreement.pdf

Originally Published by By ROI-NJ, Anjalee Khemlani
Trenton | Apr 30, 2018 at 6:55 am : https://www.roi-nj.com/2018/04/30/healthcare/sarlo-in-letter-to-muoio-asks-n-j-to-look-into-details-of-health-insurance-contracts/

Budget and appropriations chair has questions about reimbursements, audits. State Sen. Paul Sarlo has asked Treasurer Elizabeth Muoio about the state heath plans’ third-party administrators. Reining In health care costs continues to be a challenge for many corporations and self-funded plans.

The story Isn’t any different for the state of New Jersey, the largest employer In the state. State Sen. Paul Sarlo (D-Wood-Ridge) is trying to find new solutions – and potentially hundreds
of millions of dollars In savings for the state – by addressing the Issue In a different way: Paying closer attention to how the state pays its contracted plan managers.

Last week, in a letter to state Treasurer Elizabeth Muoio, Sarlo asked the Department of the Treasury to determine if the health insurers are keeping any recovered funds, through savings from appeals, and if the plans are charging the state anything additional to what they pay the providers. 

Sarlo Letter to NJ Treasurer re TPA & Response

Sarlo also asked about surcharges related to out-of-state visits by plan members, and whether or not the state can cap those. 

In addition, he asked if the state is auditing Aetna and Horizon Blue Cross Blue Shield of New Jersey, the third-party administrators of the State Health Benefits Plan and School Employers’ Benefits Plan, which together cover more than 600,000 current and retired state employees and cost the state $6 billion in 2016 alone. 

The contract for both is set to expire in June, and a request for proposals with the same rules and requirements as the existing contract is currently out for bid. 

And, while the RFP adds to the timeliness of Sarlo’s request, it was not necessarily the impetus. 

Legislators began looking into the process in January after a New Jersey doctor, Rajnik “Raj” Raab, alerted them to a white paper he paid a California-based health care reimbursement recovery firm, AVYM, to produce. 

In the six-page white paper, the firm said New Jersey could save up to $1 billion annually: AVYM Transparency and Disclosure in Health Care Insurance

AVYM said such huge savings are possible because third-party administrators may not be paying back the state any savings they receive over time from claim appeals. 

Sarlo, the deputy majority leader who serves as the chair of the Senate Budget and Appropriations Committee, told ROI-NJ how such a scenario could play out. 

“Here’s what we think happens,” he said. “A public worker in town XYZ cuts his hand, severs his hand, it’s a serious accident. He incurs $50,000 worth of bills. He petitions the fund representing the town … we pay. Now they (insurers) scrutinize and, over time, after arguing back and forth, reduce it to only $40,000.” And, if the reduced amount comes after the $50,000 has already been paid to the insurers, there is no way to check or prove the extra $10,000 is returned the state. Sarlo said there is no evidence that the state has ever received a refund from the insurers. 

### 

The contract between the state of New Jersey and Aetna and Horizon, which ROI-NJ obtained through an Open Public Records Act request, shows that the practice in question is prohibited, and that the state can audit the payments at any time. 

Representatives from Horizon and Aetna declined or did not return requests for comment on the issue, pointing instead to the agreements they have with the state.  

The contract with the insurers addresses potential overpayments. 

According to the contract, the state only reimburses the insurer after the payment is made.  

“The (insurer) will be reimbursed for claim checks and electronic fund transfers to providers that have cleared the (insurer’s) bank account by the (insurer) transmitting the total amount cleared via electronic mail or facsimile machine to the Commission by 11:00 a.m., EST daily, to determine the total amount that will be funded by wire transfer to the (insurer)’s designated bank on the same day. The transmission must include a breakdown between state and local amounts,” according to the contract. 

The contract also has a provision about any overpayments or refunds: 

“(Insurer) must disclose, fully account for, and remit, to the Commission any and all funds received by it as the result of a recovery of an overpayment or incorrect payment, prescription drug rebates and other pharmaceutical revenues, or subrogation of a claim or lien. Any discounted or negotiated rates or payment arrangements, any price adjustment, or refunds, and any retroactive or supplemental payments or credits negotiated with regard to covered services received by SHBP members must be remitted to the Commission. (Administrative) fees must take into consideration this provision,” according to the contract. 

And, if the state believes there is a problem with the payments, it can audit at any time. 

“(Insurers) must cooperate in the administration of routine audits performed by the Commission or its designee, on various aspects of the administration of the Plan, including but not limited to claims processing, medical management and enrollment data.  The various audits are designed to ensure (1) contract compliance, (2) that the interface system is working properly, (3) proper payment of claims where the individual should have coverage or (4) proper rejection of claims where the individual’s coverage has terminated, and (5) correct allocation of claims according to SHBP experience groups and (6) efficient and effective medical management,” the contract said. 

“An audit may be conducted if the Commission has a reasonable and good faith belief that a situation exists that will result in harm to the Plan. Audits must encompass records held by any subcontractor or related organization and held by any entity that is a member of the contractor group of companies.” 

### 

AVYM co-founders Mark Flores and Vincent Flores told ROI-NJ that the organization specializes in helping providers navigate claims and has seen a number of questionable practices since its inception in 1999. 

The white paper looked at claims from a Sparta school employee’s surgery and suggested that the provider was only paid 50 percent of the amount originally claimed, and the remainder was pocketed by the insurer. 

“Based on court cases (cited in the paper), it seems apparent TPAs can and do hide ‘undisclosed’ administrative compensation fees within medical claims payments. These undisclosed fees, which can account for 30 to 60 percent of a plan sponsor’s health claims expenditures, are usually siphoned into the TPA variance account through ‘retention reallocations’ and ‘cross plan overpayment’ offsets, among other techniques. Based on industry estimates and national claims processing standards, we believe the New Jersey State Health Benefits Plan and the School Employees’ Health Benefits Plan can realize a $1 billion (per) year reduction in expenditures by rigorous monitoring of TPA practices,” the AVYM report said. 

Mark Flores said that the actions of the TPA occur in a black box and are not visible to the state. “The big issue is that there’s no way to confirm whether or not the doctor is receiving the amount the (state) is paying the TPA for the claim,” he said. And that could save the state at least 30 percent of its current medical claims expenditures. 

Sarlo said one of the reasons he is pursuing the matter is the insurers’ response to transparency legislation. 

“When I had in my bill, when I had transparency disclosure to follow the money on these claims, which include TPAs out to providers, they opposed that bill,” Sarlo said. “Aetna, Horizon and all the health insurers opposed that bill.” 

Sarlo hopes the answers from Muoio will result in, at the very least, changing language for the new contract with the insurers. 

“Greater transparency on the operations of these third-party administrators will help identify cost savings that should be passed on to the state,” Sarlo said in a statement accompanying the letter. “There needs to be an accounting of the savings that insurance companies retain as fees and commissions.  

“We must ensure that the majority of these savings flow to the state as they should. Every year, doctors and other health care providers complain of decreasing reimbursements. At the same time, health care consumers complain of rising premiums and increasing costs. The obvious question that needs to be asked is: Where is all the money going?” 

Sarlo told ROI-NJ he realizes the answer won’t be a cure-all for the state, but it’s one worth getting. 

“I’m not saying this is going to save the budget at the end of the day,” he said. “But it’s worth a look. 

“This is serious dollars. The state of New Jersey is paying $37,000 per employee. If we can find savings in those health care plans, we must do it.” 

In Unprecedented Move, DOL Exercises Authority to Issue Cease and Desist Order Under Section 521 of ERISA, Shut Down Fiduciaries Accused of Misconduct, “Healthcare Madoff” Scheme

The U.S. Department of Labor obtained a Temporary Restraining Order in the U.S. District Court for the Northern District of Illinois against Multiple Employer Welfare Arrangement (MEWA) service providers for allegedly failing to pay more than $26 million in member’s health bills while keeping a substantial amount of money for themselves, then siphoning off those funds to offshore Bermuda accounts. The court also ordered 2 banks to freeze 14 bank accounts that were alleged to have plan assets in them.

The court ordered Black Wolf Consulting, AEU Holdings and one of its subsidiaries removed and barred from serving as fiduciaries or service providers to the individual employer plans that participate in the AEU Holdings LLC Employee Benefit Plan, a Multiple Employer Welfare Arrangement (MEWA) established by the defendants.

The court’s order immediately appointed an independent fiduciary to oversee the MEWA’s operations, marshal and control the assets of the MEWA as it relates to the underlying participant plans, perform an accounting of the MEWA’s financial position, and determine the MEWA’s ability to pay outstanding participant health claims, according to the DOL.

The order comes on the heels of the DOL lawsuit filed on November 2, 2017 seeking declaratory and injunctive relief including a temporary restraining order and preliminary injunction to remove the fiduciaries. The Complaint also alleges multiple violations of ERISA including, using plan assets to pay excessive fees and expenses, assessing undisclosed fees to the contribution amounts, failing or refusing to pay approximately $16 million for member’s medical claims, then transferring unpaid monies to offshore bank accounts in Bermuda.

Black Wolf kept anywhere from 17 to 44 percent of the money employers and employees paid toward premiums, according to the DOL complaint.

At its height, the MEWA covered approximately 14,000 participants and beneficiaries. These participants worked for more than 560 employers in 36 different states. However the increased backlog of unpaid claims created significant problems for many members as doctors refused treatments because of unpaid bills and many members were sent to collections accounts, according to the DOL.  

Additionally, the DOL issued a cease and desist order that prevents sub-brokers and aggregators working on behalf of the MEWA from marketing it to prospective employers or from enrolling new employers. The Secretary has the authority to issue an ex parte cease and desist order pursuant to ERISA § 521(a), 29 U.S.C. § 1151(a), and its implementing regulation, 29 C.F.R. § 2560.521-1. This authority applies only to a MEWA, and the cease and desist order may be issued whenever the Secretary finds reasonable cause to believe, among other things, that the respondent(s) engaged in conduct that creates an immediate danger to public safety or welfare within the meaning of § 2560.521-1(b)(3).  29 C.F.R. § 2560.521-1(c)(1)(i)(B).

According to the DOL Memorandum:

“Over $15 million in processed claims from 2016 and over $11 million in processed claims for 2017 remain unpaid. During the same time period as these claims have gone unpaid, AEU and Black Wolf have enriched themselves substantially by paying themselves and other entities millions of dollars in “fees.” Meanwhile, hundreds of unsuspecting employers have joined the AEU Plan to provide affordable medical benefits for their employees, only to have their employees be saddled with thousands of dollars in unpaid medical claims-some facing escalating collections actions and others unable to obtain life-saving treatment.“

The Memorandum goes on to point out:

“This results in thousands of participants incurring additional medical claims that will never be paid. Current and former participants report being turned away by their doctors because claims have gone unpaid. They have had to forego life-saving treatments for cancer and other illnesses. Parents who have just given birth are saddled with unanticipated medical claims at the same time they are trying to care for their newborn children. Collections agencies are calling and knocking at their doors. Many fear for their family’s future financial security. Despite the over $26 million in current unpaid claims and the harm facing these participants, Defendants continue to seek out new, unsuspecting employers to feed what is to them, a very profitable enterprise.”

Original DOL Press Release

These new ERISA embezzlement cases are part of a growing trend consistent with the court’s Hi-Lex decisions and as well as other cases we have written about before.

This lawsuit in particular should serve as a warning and wake up call for all Plan Administrators to continually monitor their TPAs in accordance with the Plan Administrator’s statutory fiduciary duties and to discharge its duties with respect to a plan solely in the interest of the participants for the exclusive purpose of providing benefits to them.

For over 7 years, Avym Corp. has advocated for ERISA plan assets audit and embezzlement recovery education and consulting. With new Supreme Court guidance on ERISA anti-fraud protection, we are ready to assist all self-insured plans recover billions of dollars of self-insured plan assets, on behalf of hard-working Americans. To find out more about Avym Corporation’s Fiduciary Overpayment Recovery Specialist (FOR) and Fiduciary Overpayment Recovery Contractor (FORC) programs click here.

After Resolution Of Contract Negotiations, Is Damage To Members Ignored? ERISA Class Action Filed Over Medical Claim Denials; Alleges Thousands Of Pre-Approved Medical Claims Unpaid, Members Left Holding The Bag; Possibly Delay Ratification Process?

On February 26, 2015, just days after the Obama Administration sent in Labor Chief Thomas Perez and a settlement was negotiated between ILWU members and the PMA, the International Longshore Workers Union-PMA Coastwise Welfare Plan was slapped with a new class-action lawsuit alleging ERISA violations and fraud for its failure to pay possibly hundreds of millions of dollars in pre-approved benefit claims, as reported by the Los Angeles Times newspaper. The lawsuit offers hope to the thousands of members that have had pre-authorized claims denied, according to court records.

“This is about protecting the rights of American workers. It is unconscionable that a health plan would deny pre-authorized, covered medical claims from a cancer patient, thereby denying needed chemotherapy. Every health plan must comply with all applicable federal laws, ERISA and PPACA claims regulations, as well as statutory fiduciary duties, for the millions of hard-working American workers and families. Otherwise we will have a real life John Q on our hands.” said Esmeralda Alfaro, Co-Lead Counsel for the class plaintiffs.

Despite protests from thousands of ILWU members throughout CA and numerous “work stoppages” over the last 2 years and a formal complaint to the Department of Labor, EBSA Assistance and Complaints, the PMA welfare plan has allegedly refused to pay pre-authorized medical claims. The result has been calamitous for members and their relatives according to the court documents. Many have foregone much needed medical care and some have had mortgage loan applications denied due to adverse credit ratings linked directly to unpaid medical claims.

According to the complaint, the Plan’s own independent fact finder confirmed there were “286,000 unprocessed claims” at one point and the “backlog became worse, with about 90,000 new claims each month” added to the backlog.  The suit also alleges that the plan attempted to  “delay processing of legitimate claims, increasing interest income for the Plan’s fund” as well as create the “misimpression that the PMA Trustees have been diligent in the exercise of their fiduciary obligations”, according to court documents.

In accordance with this ERISA class action filing, Avym Corporation announces new comprehensive ERISA and PPACA Out-Of-Network (ONET) Medical Claim Appeal and Litigation Support Programs in accordance with the most recent federal court decisions. Avym Corporation provided plaintiff providers with ERISA appeal compliance and ERISA litigation support in this provider ERISA class action and Avym’s support services were instrumental in allowing multiple plaintiffs the chance to fight back.

Case Info: Amijo et al v. ILWU-PMA Coastwise et al U.S. District Court for the Central District of CA (Western Division- Los Angeles) Civil Docket for Case #: 2:15-cv-1403, Filed 02/26/2015.

This class action lawsuit comes on the heels of successful contract negotiations between the International Longshore Workers Union and the Pacific Maritime Association, a group of West Coast terminal operators. While the settlements still have to be ratified by union members, it remains unclear whether ILWU members view the class action lawsuit as an obstacle to delaying the ratification process. The implications of any delay in ratifying the agreements could be enormous.

According to the lawsuit,

• ILWU-PMA has been intentionally withholding and delaying payments from patients and providers on legitimate claims, thereby increasing interest payments to the Plan’s fund in violation of ERISA;
• ILWU-PMA misleads patients and providers by creating the “misimpression that the PMA Trustees have been diligent in the exercise of their fiduciary obligations” when in fact the claim back log was increasing at a rate of 90,000 additional claims per month;
• ILWU-PMA has never complied with ERISA claims regulation nor its own claims procedures by failing to provide “meaningful grievance and appeal procedures” effectively denying full and fair reviews of appealed claims in violation of ERISA;
• ILWU-PMA’s refusal to pay claims has resulted in many members and their beneficiaries foregoing medical care or treatment that is covered by the Plan to avoid damage to their credit rating or additional personal liability for covered services not paid by the Plan;
• ILWU-PMA has intentionally discouraged members and beneficiaries from seeking services from Out-of-Network providers due to the prospect of complete denials of covered, pre-authorized services, in violation of ERISA;

The putative class on behalf of all similarly situated members and providers is seeking for ERISA benefits payments due, injunctive and declaratory relief and removal of the PMA Trustees among other claims.

Avym Corporation’s ONET UCR ERISA Medical Claim Appeals and Litigation Support Programs will systematically demystify this ERISA class action lawsuit, with particular focus on the essential elements of ERISA claims regulation, successful ERISA administrative appeals as the prerequisites for ERISA judicial reviews on behalf of all similarly situated patients and healthcare providers.

The class action also alleges additional ERISA violations by ILWU-PMA for withholding newly adjudicated claim payments even after the claims were “pre-authorized” and or “pre-priced” by the plan and it’s agents. In particular, the complaint alleged the plan “now routinely denies, or fails even to process, most or all new claims for services of out-of-network Providers.”

The Complaint goes on to allege that: “Plaintiffs are informed and believe, and based thereon aver, that Defendants have paid only a few claims for reimbursement for medical expenses for services of out-of-network Providers in over one year, causing financial hardship to Participants and Beneficiaries, who by contract or otherwise are liable to Providers if the Plan does not pay. Such intentional refusals to pay also cause hardship to Providers, who are owed substantial sums, and make it increasingly difficult for Providers to continue to serve Participants and Beneficiaries, because of the growing realization that they will not be paid timely or at all.”

This ILWU-PMA case illustrates the need for all employer sponsored health plans to comply with federal ERISA regulations when making benefits determinations and payments.  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.

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.

ILWU-PMA Coastwise Welfare Plan hit with class action lawsuit in Los Angeles federal court for allegedly not paying legitimate medical claims.

Avym Corporation provided plaintiff providers with ERISA appeal compliance and ERISA litigation support in this provider ERISA class action and Avym’s support services were instrumental in allowing multiple plaintiffs the chance to fight back.

Case Info: Amijo et al v. ILWU-PMA Coastwise et al U.S. District Court for the Central District of CA (Western Division- Los Angeles) Civil Docket for Case #: 2:15-cv-1403, Filed 02/26/2015.

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.

$24 Billion Solution to High Deductible Health Plans.

Educating patients on HSA’s my not only be the right thing to do, it may also make very good business sense. The latest reports and surveys show an increase in the total number of HSA’s and an increase in the average balance ($2300). How much of the $24 Billion in medical savings/reimbursement account assets is your practice collecting?

In today’s environment of higher health insurance deductibles, increasing out-of-pocket costs and shrinking provider networks why aren’t more medical providers taking advantage of Health Savings Accounts (HSA’s)?  According to the latest reports, medical savings/reimbursement account asset balances nationwide are in the $24 Billion range. Yes, that’s Billion with a “B”!

The trends also show that HSA’s are outpacing health reimbursement arrangements (HRA’s). A health savings account or HSA, is a tax-exempt trust or custodial account you set up with a qualified HSA trustee to pay or reimburse certain medical expenses you incur. Only consumers with on a high-deductible health insurance plan can qualify for HSA’s. Consumers don’t have to set up their HSA’s with their employer; they can also set them up individually. Contributions to HSA’s may be made on a tax exempt basis and can also be made by an employer.

Any contributions made to the account stay in the account until you use them. Contrary to popular belief, with HSA’s if you “Don’t Use it-You Don’t Lose it”, even if you change jobs. While interest and other earnings in the accounts are tax free, distributions may only be tax free when used for “Qualified Medical Expenses”.

For IRS information on HSA’s, Qualified Medical Expenses and contribution limits, click HERE.

Every practice should advocate for patient’s affordable care and have HSA programs and policies in place. On Jan 10, 2015, Avym Corporation announced its 2015 HSA & PPACA Claim Specialist Programs to train both in-network and out-of-network healthcare providers on: (1) PPACA internal and external appeal laws, (2) the latest health claim overpayment ERISA laws and (3) how to get paid with $24 billion in patient HSA’s in 2015.

The two-day basic PPACA HSA Claim Specialist Program was designed to get providers paid even in the face of High Deductible Health Plans (HDHP). With HSA assets estimated to be over $24 Billion in 2015 and as high as $40 Billion by the end of 2016, the one-day basic PPACA-HSA Claim Specialist program is designed to comply with new federal laws in 2015.

The eight-day advanced Certified PPACA & ERISA Claim Specialist programs were designed to comply with 2015 full implementation of PPACA Claims regulations for both internal and external appeals for all claims denials, and especially for sky-rocketing payer overpayment claims and newly approved claim withholding or offsetting denials, in accordance with the latest Court rulings and DOL legal guidance on the increasing overpayment or repayment disputes.

Fast Facts on HSA’s:

1. Medical savings and reimbursement asset levels are growing-Assets grew to approximately $23.8 billion in 2013-up from $18 billion in 2012
2. Account balances increased-Average HSA account balance increased to $2311 in 2013-up from a little over $1400 in 2008
3. Length of time patients have with HSA account has impact-—Not surprisingly, the length of time that an individual has had an account has a major impact on the amount of money in the account.
4. Experts estimate HSA assets to be around $40 Billion by the end of 2016
5. HSA’s can pay for transportation expenses-In cases of emergency, HSA funds can be used to pay ambulance bills; also people with mobility issues can use HSA funds to pay for taxi or shuttle services to and from medical facilities.

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.

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

On April 7, 2014 and April 28, 2014, the Obama administration’s Department of Labor (DOL), argued in the 9th and 5th Circuit Courts, on behalf of out-of-network providers and patients against health plans, on whether providers must balance bill patients before billing health plans.

On April 7, 2014 and April 28, 2014, the Department of Labor (DOL), argued in the 9th and 5th Circuit Courts, advocating for out-of-network providers and patient’s rights against health plans, on whether providers must first balance bill patients before billing health plans. All out of network providers and patients should understand the court impacts of the DOL amicus briefs and oral arguments.  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.

In arguing for out-of-network patients’ right to timely, vital healthcare and against having to pay full deductibles and coinsurance upfront, the DOL effectively argued against the current out-of-network claim denial practice by United and CIGNA:

“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 signed healthcare claims or participants who are able to first to pay for the care, or the provider can recognize as creditworthy. Affirmance of the district court ruling can only benefit conflicted administrators, such as United, that both fund and administrator ERISA plans, by allowing them to forestall payments for substantially expensive medical care or maybe avoid that payment altogether”, according to the court audio records.

Avym Corporation closely monitors and demystifies the latest federal court developments for all out-of-network patient advocates and claims specialists, with new ERISA and PPACA reimbursement compliance seminars.

“The court rulings from both 9^th and 5^th Courts of Appeals will have a profound impact on the approximately 76% of Americans insured through employer-sponsored health plans, as they have paid for out-of-network coverage but may not be able to pay upfront for their full deductible and coinsurance before seeking timely, vital healthcare,” says Mark Flores, Vice President/Co-Founder of Avym Corporation and a national expert on ERISA and PPACA compliance appeals.

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, on April 7, 2014.  Oral argument recording: http://cdn.ca9.uscourts.gov/datastore/media/2014/04/07/12-17604.wma

Spindex Physical Therapy USA, Inc. Amicus Brief, in support of plaintiffs-appellants and requesting reversal: http://www.dol.gov/sol/media/briefs/spindex(A)-06-05-2013.htm

Case Info: North Cypress Medical Center, et alv. Cigna Health, Case No. 12-20695, in the United States Court of Appeals for the Fifth Circuit, on April 28, 2014.  Oral argument recording: https://www.ca5.uscourts.gov/OralArgRecordings/12/12-20695_4-28-2014.wma

North Cypress Medical Center Operating Co. Amicus Brief, in support of plaintiffs-appellants, and requesting reversal: http://www.dol.gov/sol/media/briefs/north-cypress(A)-10-30-2013.htm

Among other things, the DOL added, “Assignee physicians with validly assigned benefits claims have standing to pursue those claims regardless of whether or not if they first billed their patients,” argued Marcia Elizabeth Bove, DOL attorney for the Secretary of Labor, according to the court audio records.

“By listening to the arguments from both sides of the healthcare matrix, out-of-network providers and patients may have much better understanding on the vital difference between patients, providers and health care plans. The federal Courts of Appeals are expected to make these landmark decisions in the next a few months for the market lifespan of the out-of-network and managed care business model,” says Dr. Jin Zhou, president of ERISAclaim.com, a national expert on ERISA and PPACA compliance appeals.

December 2013 National Composition Summary from DOL Bureau of Labor Statistics:

http://stats.bls.gov/ncs/ebs/detailedprovisions/2012/ownership/private/table02a.pdf

ERISAclaim.com Announces Its Nomination of YF Corporation for the White House 2012 PPACA Champion, to be Honored for Work in Educating Others About the New Health Care Law to Raise Awareness About the Benefits of the Patient Protection & Affordable Care Act (PPACA).
>> download a printable PDF file of the article

“No one deserves to be honored in that area more than YF Corporation.”

On Feb. 15, 2012, Dr. Jin Zhou, of ERISAclaim.com announced his nomination of Vincent Flores and YF Corporation for the 2012 White House PPACA Champions of Change program, honoring their work in educating others about the new health care law in order to raise awareness about the benefits of the Patient Protection & Affordable Care Act (PPACA). Dr. Jin Zhou was encouraged by the White House Office of Public Engagement to nominate a PPACA champion to go to the White House to be honored for their work, for “educating their community about the new health
care law and helping people take advantage of the benefits from the law”. Vincent Flores and YF Corporation are nominated for their effort and success over the past two years in educating the healthcare provider community about PPACA claims regulations with free PPACA Webinars and Certified PPACA Claim Specialists programs.

“I submitted Vincent Flores and YF Corporation for the 2012 nomination of the “PPACA Nobel Prize” as the Ultimate champion in teaching others about the benefits of ACA. No one deserves to be honored in that area more than YF Corporation, as intended by the White House for 2012,” said Dr Jin Zhou, President of ERISAclaim.com, Hanover Park, IL.

“Vincent Flores and YF Corporation have been highly regarded in the Southern California provider community for educating the healthcare industry about the new healthcare law. This has allowed many providers to take advantage of the benefits within the new healthcare law by doing compliant and effective PPACA & ERISA appeals for all improperly denied healthcare claims, and to legitimately and effectively win more healthcare coverage and access for more patients. In addition, the education YF Corporation has done can be seen as an important way to advocate for Patients’ Bill of Rights, as intended by Congress”, according to Dr. Zhou.

According to the White House Office of Public Engagement, all nominations must be submitted by midnight on February 16th of 2012, (http://www.whitehouse.gov/webform/white-house-champions-change-affordable-care-act):

“White House Champions of Change”:

Affordable Care Act

The White House Champions of Change program highlights the stories and examples of citizens across the country that represent President Obama’s vision of out-innovating, out-educating, and out-building the rest of the world through projects and initiatives that move their communities forward. …… This year we are seeking recommendations of individuals and organizations that are educating others about the new health care law to raise awareness about the benefits of the Affordable Care Act.

Tell us about an individual or organization who is educating their community about the new health care law and helping people take advantage of the benefits from the law. Use the form below to nominate a champion to come to the White House to be honored for his/her work.

Please submit nominations by midnight on February 16th by utilizing this form.”

In order to nominate for “2012 PPACA Champion of Change”, one must describe in part:

“How has your nominee’s work helped educate people about the new healthcare law or take advantage of the benefits within the new healthcare law?”

Dr Zhou of ERISAclaim.com made his nomination for the following reasons, in part:
YF Corp has continued to advocate, within the healthcare industry, for continued education of the new healthcare reform law in order to take advantage of the benefits within the claims regulations by doing effective and compliant PPACA & ERISA appeals for all improperly denied healthcare claims, thus providing patients more access to health care benefits and ensuring their health care rights, as intended by Congress;

“PPACA provides 190 million Americans with much needed health coverage and appeal rights in order to access to the covered healthcare services. With new powerful PPACA claims regulations and enforcement penalties, the provider’s PPACA appeals for all improperly denied claims are the most important steps in advocating for real coverage and access to healthcare when patients need it the most, as intended by Congress,” said Dr. Zhou.

Located in Los Angeles, CA, YF Corporation is a leading multi-facet healthcare solution company with dedicated appeals specialists in billing, coding, revenue recovery services, consulting, claims review and compliance. With many physicians and ambulatory surgical centers as clients statewide, YF Corporation has been fighting for the rights
of consumers and providers by appealing denials, partial denials and overpayment requests, with ERISA training from ERISAclaim.com since 2001. YF Corporation offers FREE webinars to keep you updated on new Federal Court decisions, PPACA claims regulation enforcement and how these directly affect reimbursements.