U.S. Supreme Court: PPACA/ERISA pave the way to overcoming the No. 1 Health Claim Denials and Litigation issue in 2012 – Cost-Sharing War

U.S. Supreme Court: PPACA/ERISA pave the way to overcoming the No. 1 Health Claim Denials and Litigation issue in 2012 – Cost-Sharing War

In The Wake Of Recent Insurer Litigations, Claim Denials And Auditing Against Healthcare Providers and Patients For Alleged Deductible And Co-Insurance Waiver Practice, AVYM Offers Compliance Webinars On The Latest Supreme Court Decisions, PPACA And ERISA Regulations.

A nationwide increase in insurer litigations, claim denials and auditing against healthcare providers for alleged deductible and co-insurance waiver practices by providers, has created a need for AVYM to offer healthcare executive compliance Webinars which will include issues on the latest Supreme Court decisions, PPACA and ERISA regulations for compliance and solutions to increasing insurers national health claim denials and litigations in 2012.

AVYM Webinars will:

  1. 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.
  2. 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
  3. 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”, such as cost-sharing waiver practice faced by every patient and provider.
  4. Discuss the differences between compliant and non-compliant practices for waiver of cost-sharing.

In review of healthcare headline news of 2012, it is evident that the No. 1 payor and provider litigation and claim dispute issue that is now escalating to the top of the radar screen is a “deductible and co-insurance war” for all.

“While health care providers are being sued for not collecting patient deductibles in the west coast but also for collecting patient’s deductible and denied claims in the east coast, it cannot be said that health plans and insurer’s litigations are not all without merits. Nevertheless, the nationwide explosive and mass claim auditing and litigation should prompt all of us to ask one simple question: what does the Supreme Court, PPACA and ERISA regulations say about this new billion dollar question?”

Of particular importance, AVYM’s healthcare executive Webinar will have in-depth discussions on compliant cost-sharing waiver practices, along with when and why the claims can or cannot be denied for cost-sharing waivers and reductions:

  1. HHS/OIG Guidance on compliance for cost-sharing waivers and reductions: http://archive.hhs.gov/news/press/2004pres/20040219.html
  2. ERISA requires the administrator of an employee benefit plan to give participants a Summary Plan Description (SPD) and a summary of any material modifications (SMM) that are “sufficiently accurate and comprehensive to reasonably apprise [them] * * * of their rights and obligations under the plan.” (http://www.gpo.gov/fdsys/pkg/USCODE-2010-title29/html/USCODE-2010-title29-chap18-subchapI-subtitleB-part1-sec1022.htm)
  3. “The Summary Plan Description shall contain the following information: “circumstances which may result in disqualification, ineligibility, or denial or loss of benefits;” 29 U.S.C. §1022(b);
  4. The SMM must provide notice of changes in those circumstances, 29 U.S.C. 1022(a);
  5. The SPD and SMM must “be written in a manner calculated to be understood by the average plan participant,” 29 U.S.C. 1022(a);
  6. SPD and SMM must not have the effect [of] misleading, misinforming or failing to inform participants.” 29 C.F.R. 2520.102-2(b). 29 U.S.C. 1024(b).
  7. ERISA Civil enforcement: (a) Persons empowered to bring a civil action A civil action may be brought — (1) by a participant or beneficiary……(B) to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan; 29 U. S. C. §1132(a)(1)(B); (http://www.gpo.gov/fdsys/pkg/USCODE-2010-title29/html/USCODE-2010-title29-chap18-subchapI-subtitleB-part5-sec1132.htm)
  8. Recent Supreme Court decision on participant right and plan authority under ERISA, for cost-sharing disputes. Kennedy v. Plan Administrator for Dupont Savings and Investment Plan et al. (No. 07–636), 01/26/20089. “ERISA provides no exception to the plan administrator’s duty to act in accordance with plan documents. Thus, the Estate’s claim stands or falls by “the terms of the plan,” 29 U. S. C. §1132(a)(1)(B), a straight for-ward rule that lets employers “ ‘establish a uniform administrative scheme, [with] a set of standard procedures to guide processing of claims and disbursement of benefits,’ ”
  1. Latest U.S. Supreme Court decision for all ERISA claims: “Cigna v. Amara, (No. 09-804), 05/16/2011. “We conclude that the summary documents, important as they are, provide communication with beneficiaries about the plan, but that their statements do not themselves constitute the terms of the plan”. (http://www.supremecourt.gov/opinions/10pdf/09-804.pdf)
  1. PPACA & ERISA claim regulations on claim denials and appeals due to deductible and co-insurance waiver dispute and litigations. (http://www.dol.gov/ebsa/healthreform/)

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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