New Programs Help Navigate Reimbursement Laws

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WASHINGTON—ERISAclaim.com this week announced that 2012 Patient Protection And Affordable Care Act (PPACA) and Employee Retirement Income Security Act (ERISA) claim-specialist certification programs will be available for out-of-network (OON) providers, ambulatory surgical centers and hospitals.

The certification programs are designed to train providers to comply with new federal healthcare reform laws, PPACA and new U.S. Supreme Court decisions on ERISA, and are provided as new solutions to the escalating OON reimbursement and overpayment crisis. The key topics the certification programs will include: OON providers' rights to receive insurance checks directly, rightful UCR reimbursement rates under PPACA and ERISA, patients' rights to choose OON providers, and PPACA and ERISA protections against all alleged overpayment recoupment and payor SIU pre-payment review delays and denials.

The Advanced 2012 PPACA and ERISA claim-specialist certification programs will offer new OON compliance training to prevent and defend against the most prevalent healthcare payor fraud allegations, claim denials and delays which include: cost sharing fraud (co-pay & deductible waiver), billing and coding fraud (upcoding and unbundling), medical necessity fraud and documentation fraud.

In 2012, the PPACA claims regulations will be fully implemented and enforced for all health plans, as well as the majority of all healthcare claims outside of Medicare and Medicaid programs.

PPACA adopted the 36-year-old federal law ERISA, in its entirety, as minimum standards for all health plans. ERISAclaim.com's PPACA and ERISA claim specialist program is one of only programs in the nation developed for healthcare providers and reimbursement professionals.

"PPACA and ERISA are the pre-eminent federal laws governing health claims, especially OON provider claims. The latest congressional study reported a 39 percent to 59 percent reversal of claim denials if appealed under ERISA, but only less than 0.5 percent of denials were appealed in the state of Ohio. The lack of ERISA education and ERISA-compliant appeals is a primary reason providers turned to questionable or even alleged fraudulent claims practices," said Dr. Jin Zhou, president of ERISAclaim.com, a national expert on PPACA and ERISA appeals and compliance.

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