Patients' and Providers' Right to Appeal Payer Denials Strengthened by Federal Government

To make sure that healthcare providers are protected from years-long fraud investigations by payers that may ultimately deprive them of significant income, the U.S. government has set up the ERISAclaim.com 2012 Advanced SIU ERISA & PPACA Appeals Programs.

This all came about when a Texas federal court found on behalf of Aetna, which had investigated a healthcare provider, then denied his claim and ended his contract, taking so long to get back to him that he missed the window of opportunity for an appeal under The Employee Retirement Income Security Act of 1974 (ERISA).

ERISA guarantees certain categories of employees’ healthcare after some period at their employer.

But even though Aetna won this case, officials are still on the lookout for payers who sit on claims so long, and, as in this case, wind up denying the provider the time needed to pursue appeals, and ultimately, lose the income. The new appeals program should help with that.

According to the story, providers nationwide are “increasingly and epidemically under the payer's Special Investigation Unit (SIU) without proper compliance with the Patient Protection and Affordable Care Act (PPACA) and ERISA claims regulations, for both purported or alleged healthcare fraud. . . without disclosing and affording providers or patients the ERISA & PPACA rights to appeal.”

The whole problem is that a provider’s claim can be investigated by a payer for months or even years, running the clock out for a timely ERISA appeal, where the claim should originally have gone, and thereby ensuring non-payment, inevitably leading to “disastrous revenue loss in year-long claims or frequently provider bankruptcies,” according to the press release.

According to a story at comucap.org, court documents showed that the provider plaintiff had been a PPO provider for more than 10 years since 1997 with Aetna and was paid by Aetna without issues.

 In 2007, “Aetna SIU audited the plaintiff and made a $59,000 overpayment refund demand, and then ‘stopped paying for all Provider Services for all patients which it had routinely and consistently paid in the past,’” the story says. It goes on to note that, after that, Aetna terminated the provider agreement altogether.

The provider then sued Aetna for more than $119,000 in unpaid claims in the Texas state court, according to the story. The case then went to the Supreme Court on the grounds that the provider’s contract claims “raised federal claims ‘in character’ because they were preempted by the Employee Retirement Income Security Act of 1974.”

"While it is perfectly legitimate for a health plan fiduciary to safeguard plan assets and fight against all healthcare fraud and abuse, it is also extremely important for health plan fiduciary to comply with ERISA fiduciary duties and claims regulation,” said Dr. Jin Zhou, president of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance, in the story.  “PPACA and ERISA are the pre-eminent federal laws governing health claims, especially out-of-network provider claims. The latest congressional study reported a 39 percent to 59 percent reversal of claim denials if appealed under ERISA.”

“It is clear that no one can wear two hats at the same time by playing a Guardian Angel as a fiduciary and an investigator as a prosecutor simultaneously,” Dr. Zhou added in the story.  “Our healthcare system must strike a balance between putting real criminals behind the bars and protecting the vast majority of honest patients and healthcare providers.”

Want to learn more about the latest in communications and technology? Then be sure to attend ITEXPO East 2012, taking place Jan. 31-Feb. 3 2012, in Miami, FL. ITEXPO offers an educational program to help corporate decision makers select the right IP-based voice, video, fax and unified communications solutions to improve their operations. It's also where service providers learn how to profitably roll out the services their subscribers are clamoring for – and where resellers can learn about new growth opportunities. For more information on registering for ITEXPO registration click here.

Stay in touch with everything happening at ITEXPO. Follow us on Twitter.