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

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

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

The timing of the PPACA Program, scheduled for Sept 15, 2012 is appropriate in light of recent CMA Press and LA Times Report, allegedly confirmed by Aetna, that Aetna is terminating or kicking out all 35,000 members of CMA as a result of the on-going court battles.  The PPACA Ex-PPO Programs are designed to provide 35,000 California doctors with compliant solutions to patient’s right to choose and protections under the new federal health reform law.  On June 28, 2012, the Supreme Court upheld PPACA’s constitutionality.

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

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

CMA Letter to Aetna

CMA Letter to Aetna Lawyers

According to a LA Times Report on 08-30-2012, “Dispute between Aetna, California Medical Assn. heats up: California Medical Assn. accuses insurer Aetna of refusing to negotiate with member doctors or kicking doctors out of its network as retaliation for a lawsuit.”

As reported on 08-30-2012 by a Press Release from CMA, California Medical Association, “California Medical Association calls on Aetna to stop retaliatory behavior against physicians”.   Dr. James T. Hay. M.D., CMA president, was quoted as saying: “Aetna is essentially saying that they will no longer do business with the 35,000 members of CMA.”  http://www.cmanet.org/news/press-detail/?article=california-medical-association-calls-on-aetna

“While we cannot pass any judgment on the merits of the court allegations from Aetna or the CMA, as that judgment is entrusted to the Courts, we can provide PPACA compliant solutions for providers to fully and properly disclose any self-referrals and/or out-of-network referrals in accordance with all applicable federal and state laws, and to act as the patient’s advocates for patient’s right to choose and to appeal all claim delays and denials under ERISA and PPACA.”, said Mark Flores, PPACA ERISA Claim Specialist, co-founder of AVYM Corporation in Los Angeles, California.

As reported by an American Medical Association news report on June 26, 2012, according to the Kaiser’s Health Security Report in June 2012: “Insured, High-Income Patients Delay Medical Care, Too: Even among people who make $90,000 or more per year, nearly 40% skipped or delayed care because of cost”.  http://www.ama-assn.org/amednews/2012/06/25/bise0626.htm

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

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

  1. DOL Affordable Care Act Regulations and Guidance: http://www.dol.gov/ebsa/healthreform/
  2. DOL: About 77% of Insured Americans Purchased Out-Of-Network Coverage under Private Industry (DOL, BLS, NBS 2010, page 11 of 67):   http://stats.bls.gov/ncs/ebs/detailedprovisions/2010/ebbl0047.pdf
  3. Congressional GAO Reports: 39% to 59% denial reversal with valid appeals, only 0.5% appeals in Ohio –http://www.gao.gov/new.items/d11268.pdf
  4. ACA Indigency Discount v. PPO discount: http://archive.hhs.gov/news/press/2004pres/20040219.html
  5. Disclosures on estimated charge for each and all services, network participation status, billing and collection policies.
  6. Guaranteed Patient Satisfaction (GPS) for total disclosure and transparency on referring provider affiliation and remuneration arrangement, if any.
  7. PPACA/ERISA appeal assistance for both in-network and out of network claim delays and denials.
  8. OIG HEALTH CARE COMPLIANCE PROGRAM TIPS: http://oig.hhs.gov/compliance/provider-compliance-training/files/Compliance101tips508.pdf


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

Located in Los Angeles, CA, AVYM is a leading provider of services focusing entirely on the resolution of denied or disputed medical insurance claims by participating in the nation’s first ERISA PPACA Claims Appeals Certification program.  AVYM also offers free Webinars, basic and advanced educational seminars and on-site claims specialist certification programs for doctors, hospitals and commercial companies, as well as numerous pending national ERISA class action litigation support.



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