Large Insurers UNITEDHEALTHCARE, AETNA And HUMANA To Promote ERISA And PPACA Appeals Process Regardless Of Supreme Court Decision

Large Insurers UNITEDHEALTHCARE, AETNA And HUMANA To Promote ERISA And PPACA Appeals Process Regardless Of Supreme Court Decision

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.”


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.”


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.


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.



Leave a Reply

Your email address will not be published. Required fields are marked *