Category Reports

All employer sponsored health plans must 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.  Providers should submit compliant appeals requesting due process and a full and fair review.

The number of stories appearing in the national media regarding medical claim denials, audits and recoupments by health insurers are growing every day. With the passage of PPACA by congress and the U.S. Supreme Court ruling, more and more media outlets are asking questions about how insurers conduct business.   

As insurance companies increasingly fight to contain costs and recoup allegedly improper payments to health care providers, a spike in lawsuits has occurred and may be attributed to newly empowered healthcare providers pursuing ERISA, a federal law, in order to level the playing field against insurer’s denials and recoupment claims.

The crux of the issue is whether alleged overpayment recoupment attempts are billing issues, or retroactive claim denials, thereby triggering ERISA rights and review processes.  Because recoupment attempts by insurers typically go as far back as possible in order to retrieve payments made years ago, the total dollar amount at issue nationwide is tremendous.  According to industry estimates, successful industry overpayment recoveries have reached into the billions of dollars nationwide over the past 5 to 7 years.  Thus recoupment, when used as an anti-fraud initiative, has become an increasingly popular source of revenue for insurers.   While it is important to implement anti-fraud initiatives in healthcare today, it is critical that every health plan comply will all applicable federal laws, ERISA and PPACA claims regulations, as well as statutory fiduciary duties.

Besides the obvious monetary implications, there are other sweeping consequences.  Should the courts rule these alleged overpayment recoupments are not preempted by ERISA, insurers would be able to move even more aggressively in their recoupment practices thereby creating a nearly insurmountable task for providers when challenging insurer payment policies.  Additionally, patients could be caught in the crossfire of these recoupment practices causing financial hardship and in some cases bankruptcy.

On the other hand, if the courts determine recoupments of allegedly overpaid claims are indeed retroactive claim denials, thereby triggering ERISA rights and review processes, 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.

Nevertheless the issue of whether the practice by insurance companies of recouping money from providers for alleged overpayments, sometimes by withholding payments for covered services from other patients is an issue that has not been clearly defined by the courts –until now.  There does seem to be a growing consensus on the interpretation of these practices.

In a recent case before the Third Circuit, the U.S. Department of Labor filed an Amicus Brief in support of plaintiff providers in an overpayment ERISA class-action urging judges to allow a lawsuit against Aetna Inc. to proceed under ERISA, which allows for appeal and review rights protections for providers before insurers can recoup reimbursements.

The DOL’s position on the pertinent issues included:

• Aetna must comply with federal law ERISA for all post-payment overpayment demands due to ERISA plan coverage dispute guidelines;
• A healthcare provider with a valid assignment has federal rights to ERISA appeals and lawsuit in federal court;
• Post-payment, retroactive, overpayment demand is an ERISA adverse benefit determination, triggering full and fair reviews guaranteed under ERISA;
• Aetna’s hypothetical state law claims of fraud may not short-circuit federal ERISA procedural protections for both in-network and out of network providers and patients.

This is the first time the federal government had effectively clarified and interpreted federal law ERISA as the primary governing law for all overpayment conflicts due to plan coverage disputes. The significance and timeliness of the DOL’s action in federal appeals court cannot be overstated, as it came less than two months after a federal court in Chicago reached the same conclusion for plaintiff providers in another provider ERISA overpayment class-action against numerous Blue Cross Blue Shield entities.

The profound impact of these decisions is that they protect patients and providers under the federal law ERISA in all overpayment disputes with ERISA plans.

Ironically, providers have tried suing insurers for claim denials and unauthorized recoupments in state courts seeking punitive monetary damages only to have insurers successfully remove these cases to federal courts through ERISA preemption.  Now it seems the providers have started to catch on.

Furthermore, in federal court, even if the insurers were granted equitable relief insurers would face a difficult task because many payments would have been paid sometimes years earlier.  Funds must be traceable and segregable, that is they must be identifiable.  “In reality, it is nearly impossible to trace the funds in these circumstances,” according to D. Brian Hufford, a senior partner at Pomerantz Grossman Hufford Dahlstrom & Gross LLP who in May won a recoupment suit in Rhode Island federal court against a Blue Cross Blue Shield plan.

Hufford said a goal of the Rhode Island case was to set the table for bigger victories. “We are trying to set precedents,” Hufford said.  The Rhode Island win, he added, “sends a strong message to providers around the country that if they’ve had this happen to them, they have an opportunity to fight back.”

In that case the United States District Court for The District of Rhode Island ruled against BCBSRI in a landmark lawsuit for overpayment recoupment against two healthcare providers for alleged fraudulent billings. Furthermore the court ruled in favor of the provider defendant’s counterclaims against BCBSRI for withholding monies from future claims.  While relying upon relevant recent Supreme Court decisions, among other things, the court decided the following:

1. Federal law ERISA is the only mechanism available to BCBSRI regardless of BCBSRI PPO contract;
2. As a matter of ERISA law, BCBSRI can make no recovery for past payments and can withhold no money from future claims;
3. Both healthcare providers were absolved of wrong doing as BCBSRI failed to present “clear and convincing evidence” to support fraud, medically unnecessary or mis-coding allegations;
4. The two providers were not “given any opportunity to appeal or have Blue Cross’s determination reviewed, despite the inclusion of review procedures both under ERISA and the Provider (PPO) Agreements.”
5. Whatever monies BCBSRI paid to both healthcare providers for alleged fraudulent billing and non-medically necessary treatments, rightfully, equitably, and in good conscience belongs to the providers;
6. BCBSRI cannot recover the monies already paid out to the providers because those monies are not subject to equitable lien from the BCBSRI PPO contract overpayment provisions.
7. The court rules for the provider’s counterclaims against BCBSRI for withholding money from future claims and orders BCBSRI to return all monies withheld from future claims with prejudgment interests and attorney fees to be determined by the court.

Simply put, all employer sponsored health plans must 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.  Providers should submit compliant appeals requesting due process and a full and fair review.  Additionally, as a matter of best practices, all healthcare providers should comply with ERISA claims regulations using a valid ERISA compliant designation of authorized representative before appealing any claim (be it an overpayment recoupment or any other type of denial) on behalf of any member of any employer sponsored health plan.

To find out more about PPACA Claims and Appeals Compliance Services email info@avym.com or visit our website www.avym.com

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.

Avym Corporation announces 2013 PPACA & ERISA Claims Specialist Educational Program for Plan Administrators and TPAs, in order to comply with 2013 full implementation of PPACA claims regulations. 

Avym Corporation (Avym) announces 2013 PPACA & ERISA Claims Specialist Educational Program for Plan Administrators (PA) and Third Party Administrators (TPAs).  This program is the first of its kind in healthcare history and is designed to comply with 2013 full implementation of PPACA claims regulation, at a time when 82.1% of large health plans (>500) are self-insured.

Avym offers these programs as the Employee Benefits Security Administration (the arm of the U.S. Department of Labor that enforces Title I of ERISA) ramps up audits of group health plans.  The EBSA has updated its audit protocols to include a review of plans’ compliance with the Patient Protection and Affordable Care Act (PPACA) in consequence of the fact that in 2013, failure by plan administrators and TPAs to substantially comply with PPACA and ERISA claims regulations may result in substantial administrative penalties, legal liabilities and court costs.  The new federal health care reform law, PPACA, went into effect on March 23, 2010, and PPACA claims regulation went into effect on September 23, 2010.  PPACA adopts ERISA claim regulations of 37 years in its entirety as minimum internal appeal standards.

Avym Corporation’s 2013 PPACA & ERISA Claims Specialist Educational Program for Plan Administrators (PA) and TPAs is timely in light of a recent 5th Circuit court decision on January 4^th , 2013, affirming a district court ERISA decision against a TPA in awarding $453,000 in attorney fees and $512,000 in medical bills for making claims denial and appeal decisions.

(The court case information: LifeCare Management Services LLC v. Insurance Management Administrators Incorporated, No. 11-10733, Filed on January 4, 2013, United States Court of Appeals, Fifth Circuit)

“The DOL Fiduciary Guidance for all TPAs in “Maintaining the Plan’s Benefits Claims Procedure” states “While many plans hire benefits professionals or insurance companies to process claims, it is important for an employer to understand the requirements before selecting a service provider who can comply with the standards.” commented Vincent Flores, President and co-founder of AVYM Corporation and certified PPACA and ERISA claims specialist. (http://www.dol.gov/ebsa/publications/ghpfiduciaryresponsibilities.html)

Avym’s programs are immediately available to the public in both basic and advanced private certification programs.  No such known public programs of its kind have ever been made available in 37 years of existing ERISA regulation.  These programs are educational in nature to assist all plan administrators and TPAs maintain compliance with PPACA and ERISA mandates in order to:

• Contain healthcare costs
• Protect plan participants and beneficiaries in fulfilling plan fiduciary duties
• Improve health care quality and patient- provider relationships

The basic programs will be two days, the advanced private certification programs will be eight days. The pricing for these programs will depend upon the number of attendees in each group session.

“If every healthcare provider is required to obtain a medical license and/or credentialing to perform services in order to be paid then it stands to reason that every TPA or plan fiduciary should have at least some minimum ERISA or PPACA education, license or certification in order to manage claim denials and appeals from healthcare providers and patients,” noted Mark Flores, Vice President and co founder of AVYM Corporation, and certified PPACA and ERISA claims specialist.

The greatest way to contain healthcare costs and at the same time shield fiduciary liabilities is proactive compliance with all governing laws when making claim denials and appeal decisions under ERISA and PPACA.

“Nearly 82.1% of large health plans (>500 employees) are self-insured at least one plan, according to the HHS and DOL PPACA “Report to the Congress on a Study of the Large Group Market”, and in 2013, PPACA claims regulations are in full implementation and enforcement, after the Extension of Non-Enforcement Period expired,” said Dr. Jin Zhou, president of ERISAclaim.com, a national expert in ERISA and PPACA compliance, who educated healthcare providers in ERISA and PPACA appeals for more than 12 years.( http://www.dol.gov/ebsa/newsroom/tr11-01.html)

Employer Self-Insurance Decisions and the Implications of the Affordable Care Act (ACA) 

Large Group Health Plans Study 

Avym certification programs are only for personal attendance in private studying of the subject materials specified in each individual program for advancing educational knowledge with respect to applicable PPACA and ERISA compliance.

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

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

On July 16, 2012, California Department of Managed Health Care ordered Anthem Blue Cross to stop trying to collect millions in reimbursement from providers for medical claims the health plan thinks were overpaid.

Avym announces free executive webinars designed to examine the California Department of Managed Health Care’s order and discuss the profound impact of the entire overpayment recoupment market, estimated to be in the billions of dollars.

State regulators ordered Anthem Blue Cross on July, 16 2012 to stop trying to collect millions in reimbursement from providers for medical claims the health plan alleges were overpaid.

California State law allows health plans to seek reimbursement for overpaid medical claims within a year of the payment date. In order for a plan to collect on claims more than a year old, it must demonstrate fraud or misrepresentation by the provider.

Earlier this year, the California Department of Managed Health Care (DMHC) investigated collection attempts by Anthem Blue Cross between 2008 and 2011 and found the plan tried to collect overpayments from at least 535 providers for claims that were more than a year old. Anthem did not provide evidence of fraud or misrepresentation, the agency said in a news release Monday.

The plan alleged providers had improperly coded the claims using upcoding, unbundling or miscoding procedures, the cease-and-desist order shows.

Anthem, which is based in Thousand Oaks, CA, tried to collect payments from another 13 providers who allegedly had billed for services they had not rendered.

“Health care providers should not face unexpected demands for reimbursement of medical claims they believe were appropriately paid years ago,” agency director Brent Barnhart said in the release. “Anthem’s recoupment practices violate California law and are unfair to providers who are acting in good faith.”

Anthem spokesman Darrel Ng stressed in a prepared statement that the issue does not involve patient care or safety: “The issue is about Anthem Blue Cross’s efforts to keep health care affordable,” he said. “Anthem Blue Cross believes medical providers should be compensated for services provided, but should not receive payment twice for the same procedure.”

According to Mr. Ng, Anthem sought reimbursement for overpayments due to double billing which is consistent with guidelines from the American Medical Association.  “We will closely examine today’s action by DMHC and are considering our options,” he said.

Many providers are still trying to figure out what to do in light of the DMHC’s order.  The California Medical Association (CMA), which made the initial request to the DMHC to investigate, issued a press release urging the DMHC to take further action, including imposing heavy fines to deter future abuses. CMA is also asking DMHC to require Anthem refund to physicians any overpayments collected in violation of the law.

No decision has been made about whether the collected alleged overpayments will have repaid, but DHMC offered this advice: If a provider receives (or has received) a notice from Anthem (or any plan) requesting recoupment of alleged overpayments from claims older than one year, they should first file an appeal with the plan. If the appeal is unsuccessful, the plan is non-responsive or they are unsatisfied with the response, the provider should file a complaint with the DMHC Provider Complaint unit at: http://www.dmhc.ca.gov/providers/clm/clm_comp.aspx

This comes on the heels of Anthem’s recent troubles with the CA DMHC.  In January of 2012, Anthem was ordered pay doctors and hospitals money owed for services going back to 2007.  The action is a result of Anthem’s refusal to remediate providers following a financial claims audit that identified errors in payment of medical claims

This is in addition to a lawsuit, intended to be a class action, filed by consumer advocate group Consumer Watchdog.  the complaint challenges alleged “bait and switch” tactics affecting more than 100,000 individual plan members hit by deductible increases and other changes in May. It also targets other changes that allow Blue Cross to alter terms of health plan contracts several times in a year, with 60 days’ notice.

What does this mean to overpayment request by payors?  AVYM offers free webinars that will examine the importance of appealing overpayment requests, including an analysis of the GAO Report findings “When denied reimbursement by an insurance company, one of the biggest mistakes made is not appealing the decision. When denied reimbursement for services you have the right to appeal and the Insurance Company/Plan Administrator is required to explain why they denied the claim. Doing so often pays off, with an estimated 59 percent of appeals being decided in favor of the claimant.”

Avym webinars will:

• Focus on the number one healthcare dispute right now in the U.S. against health plans, providers and patients as well as the relevance of recent US Supreme Court decisions and their effects on claims denials, audits, and litigation of claim disputes. 77% of insured Americans under employer sponsored health plans are affected by these issues;
• Analyze the new federal health reform law, PPACA claim regulations, which have adopted ERISA law as the minimum claim regulations standard for all health plans which now includes individual market claims outside of Medicare;
• Analyze and discuss ERISA claim regulation which, for the last 36 years, has provided very specific provisions regulating the “circumstances which may result in disqualification, ineligibility, or denial or loss of benefits”;

To find out more about ERISA/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.

On June 12, 2012, According to a unit of UnitedHealth Group Inc., (NYSE: UNH) it will “will stick with some of the patient relationship requirements set by the federal Patient Protection and Affordable Care Act of 2010 (PPACA) no matter what the U.S. Supreme Court concludes about the constitutionality of the law.”

“UnitedHealthcare also will continue to follow the new appeals process standards”.

The Patient Protection and Affordable Care Act (PPACA) was signed into law by President Obama on March 23, 2010.  PPACA claims regulations will govern all claims processing, reimbursement, denials and appeals for almost all healthcare claims outside Medicare: ERISA claims and non-ERISA claims as well as all individual policies.  PPACA claims regulations adopted ERISA claims regulation in its entirety as PPACA internal appeals process, and adopted NAIC’s external model as PPACA external appeals process.

If a health plan fails to strictly adhere to all requirements of the new federal appeals regulations, claimants who appeal have immediate and powerful protections and remedies which include expedited external appeals, continued coverage and Lawsuits (including possible monetary damages).  These regulations set forth six new requirements in addition to those in the DOL claims procedure regulation:

• Clarification of meaning of adverse benefit determination
• Expedited notification of benefit determinations involving urgent care
• Full and fair review
• Avoiding conflicts of interest
• Notice (New EOB Standards)
• Deemed exhaustion of internal claims and appeals processes.

According to a White House Press Examiner release, among the provisions that UnitedHealth will continue to promote are  “Providing Clear and Timely Options for Appeals-UnitedHealthcare will continue to ensure that consumers are offered a simple, accessible external appeals channel and a process that is clear and timely. The company will give consumers notice of available appeals processes and the opportunity to review their files and present evidence as part of the appeals process.”

UnitedHealth President, Stephen Hemsley, stated that “that the company is voluntarily agreeing to keep the standards because the standards promote access to quality care and can help control health care costs.”

(http://www.examiner.com/article/unitedhealthcare-will-offer-obamacare-regardless-of-the-us-supreme-court-ruling)

On June 13, 2012, Humana Inc. (NYSE: HUM) announced that it will also maintain important health care insurance protections that were included in the 2010 health care reform law, no matter how the U.S. Supreme Court rules in the case pending before the Court. Humana is the second major health insurance provider to authenticate The Patient Protection and Affordable Care Act (PPACA).

Among the PPACA provisions Humana will continue to enforce are ERISA PPACA appeals rules: “Humana will continue to provide a clear and simple process for appealing claims decisions, as well as the option for health plan members to have their cases reviewed by independent review organizations. Humana believes in providing a clear, timely and accessible avenue for health plan members to appeal and resolve disagreements.”

(http://www.examiner.com/article/humana-will-also-offer-obamacare-regardless-of-the-us-supreme-court-ruling)

On June 14, 2012, AETNA joined UnitedHealth and Humana in pledging to keep key elements of the PPACA.  Even as more companies are expected to follow suit, the three companies pledge that regardless of how the U.S. Supreme Court rules in the case currently pending before the Court, major provisions will remain part of the coverage.

According to the latest White House Press Examiner release, among the specific provisions that will be extended by UnitedHealthcare, Humana, and Aetna is the provision that provides clear (and timely) options for appeal.

(http://www.examiner.com/article/aetna-joins-unitedhealthcare-and-humana-pledge-to-keep-portions-of-obamacare)

In spite of the fact that the U.S. Supreme Court is expected to rule shortly about the constitutionality of the act, more healthcare insurance providers, in addition to the three already announced, are expected to follow suit and adopt the same major portions of the law.

AVYM offers free webinars that will examine the importance of appealing denied claims, including an analysis of the GAO report findings “When denied reimbursement by an insurance company, one of the biggest mistakes made is not appealing the decision. When denied reimbursement for services you have the right to appeal and the Insurance Company/Plan Administrator is required to explain why they denied the claim. Doing so often pays off, with an estimated 59 percent of appeals being decided in favor of the claimant.”

Avym webinars will:

• Focus on the number one healthcare dispute right now in the U.S. against health plans, providers and patients as well as the relevance of recent US Supreme Court decisions and their effects on claims denials, audits, and litigation of claim disputes. 77% of insured Americans under employer sponsored health plans are affected by these issues;

• Analyze the new federal health reform law, PPACA claim regulations, which have adopted ERISA law as the minimum claim regulations standard for all health plans which now includes individual market claims outside of Medicare;
• Analyze and discuss ERISA claim regulation which, for the last 36 years, has provided very specific provisions regulating the “circumstances which may result in disqualification, ineligibility, or denial or loss of benefits”;

To find out more about ERISA/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.

Contributary Plans Criminal Project

U.S. Department of Labor

Employee Benefits Security Administration

October 2011

Millions of American workers share in the costs of employee benefits by contributing to employer sponsored retirement and health benefit plans. In 2010, the Department of Labor’s Employee Benefits Security Administration (EBSA) initiated the Contributory Plans Criminal Project (CPCP) to combat criminal abuse of contributory benefit plans.

National Compensation Survey:
Health and Retirement Plan Provisions in Private Industry in the United States, 2010;
U.S. Department of Labor Hilda L. Solis, Secretary
U.S. Bureau of Labor Statistics
Keith Hall, Commissioner
August 2011
Bulletin 2770

Health and Retirement Plan Provisions in Private Industry in the United States PDF file
Ramifications of the Report:
According to Govt Report, over 70% of insured Americans have out-of-network (OON) coverage.

DOL: About 77% of Insured Americans Purchased Out-Of-Network Coverage in Private Industry

(BLS, NBS 2010, page 11 of 167): http://stats.bls.gov/ncs/ebs/detailedprovisions/2010/ebbl0047.pdf

The National Compensation Survey has released data on health and retirement plans in private industry for 2010. The bulletin provides updated information on health plans provisions for fee-for-service plans and health maintenance organizations, and new data on high-deductible and consumer-driven health plans. Detailed information on types and provisions of defined benefit and defined contribution retirement plans are also included. This bulletin is available at http://www.bls.gov/ncs/ebs/#bulletin_details. Additional benefits data are available on the National Compensation Survey web page at http://www.bls.gov/ncs/ebs.

GAO-11-268 March 16, 2011
Ramifications of Report:

When denied reimbursement by an insurance company, one of the biggest mistakes made is not appealing the decision. When denied reimbursement for services you have the right to appeal and the Insurance Company/Plan Administrator is required to explain why they denied the claim. Doing so often pays off, with an estimated 59 percent of appeals being decided in favor of the claimant.

Data on Application and Coverage Denials

“Further, the data GAO reviewed indicated that coverage denials, if appealed, were frequently reversed in the consumer’s favor. For example, data from four of the six states on the outcomes of appeals filed with insurers indicated that 39 percent to 59 percent of appeals resulted in the insurer reversing its original coverage denial……Ohio data indicated that 0.5 percent of claim denials were internally appealed.”