Health
Reform for Out-Of-Network Providers:
Receiving
Insurance Checks Directly from an ERISA Plan?
© JIN ZHOU, President,
ERISAclaim.com
April
5, 2010
Health Reform for
Out-Of-Network Providers: Receiving Insurance Checks Directly? –
Free Webinars on Why and How
04/05/2010, Hanover Park, IL
ERISAclaim.com Expanded Its Free
Webinars to Cover New Obama Health Reform and Reimbursement Laws for
Out-Of-Network Non-Participating Provider's Rights to Receive
Insurance Reimbursement Checks Directly with Valid Assignment and
Nondiscrimination Protections for Nonparticipation. New Obama Health
Reform Law Mandates Every Group and Individual Health Plan to Accept
Patient Assignment to Send Reimbursement Checks Directly to Providers
Regardless of Participation, by Incorporating Existing Federal Law,
ERISA, and in Consistent with Recent U.S. Supreme Court Orders.
ERISAclaim.com's ERISA Appeal CD Book & Systems
and Seminars Provide Complete Sample Forms and Letters to Assistant
Out-Of-Network Providers to Exercise ERISA Rights, Including Right to
Receive Reimbursement Checks Directly From Payors.
Hanover Park, IL (PRWEB) April 5, 2010 –
ERISAclaim.com announced special coverage of its free webinars to
discuss recent Obama health reform law for out-of-network
non-participating provider's rights to directly receive insurance
reimbursement checks with valid ERISA assignment of benefits and
non-discrimination protections regardless of non-participation.
Patient Protection and Affordable Care Act, PPACA, went into effect
upon the enactment of the act on March 23, 2010. PPACA incorporates or
adopts existing
federal law, ERISA, for all group and individual health plans to
mandate unconditional acceptance of valid patient assignments for
disbursement of reimbursement checks directly to the designated health
care providers regardless of their network participation. A recent
United States Supreme Court ruling ordered ERISA plan administrators
to disburse benefits solely based on plan document and valid
assignment instead of any external documents. About 70% of insured
working Americans paid higher premiums for out-of-network coverage and
rights to see nonparticipating providers on UCR fee schedules.
ERISAclaim.com has been offering free
webinars on new health reform laws for doctors and hospitals since the
House of Representatives passed its version of health care reform
bills in last November. Due to the overwhelming reception from the
webinar attendees and increasing demand from non--participating
providers for such topics, as result of recent announcement from many
major insurance companies that no insurance reimbursement checks will
be sent to out-of-network providers.
The Webinars will cover very specific
provisions, §2719 and §2706, of new healthcare reform law, Patient
Protection and Affordable Care Act, PPACA, in reference to mandatory
compliance with the established ERISA claim regulation in its
entirety,
ERISA §2560.503-1 for every group health plan an individual plan.
ERISA
§2560.503-1 (b)(4) prohibits any anti-assignment practice and
discrimination by any group health plan in refusing to disburse
benefits checks with valid patient assignments. Department of Labor,
DOL, issued enforcement guidelines, DOL ERISA FAQ, B3, in explaining
plan administrator’s fiduciary duties in compliance with ERISA
assignment requirement. United States Supreme Court ruled on January
26, 2009 in Kennedy v. Plan Administrator for DuPont that ERISA
plan administrators must make benefits determination and benefits
disbursement decisions solely based on plan documents and valid
participant assignment.
According to Dr. Jin Zhou, president of
ERISAclaim.com, a national ERISA expert, and reimbursement compliance
consultant, it is increasingly popular from industry existing practice
that health care providers historically ignored these protections from
federal law, ERISA, in failing to secure valid ERISA Legal Assignment
for Benefits from their patients, therefore insurance companies and
health plans will have no obligations to any health care providers in
absence of valid ERISA assignments, in accordance with DOL claim
guidelines, ERISA FAQ, B2. On the other hand, if with a valid ERISA
assignment, and an insurance company or health plan must send
reimbursement checks directly to healthcare providers as a designated
and authorized representative, regardless of network participation,
pursuant to DOL ERISA FAQ B3. Dr. Zhou also explained ERISA claim
regulation has outlawed industry anti-assignment practice since
January 2003.
Patient Protection and Affordable Care
Act, PPACA §2706, went into effect upon its enactment of
the act, on March 23, 2010, after President Barack Obama signed PPACA
into law.
Patient Protection and Affordable Care Act, PPACA, specifically
prohibits any discrimination against any health care providers
regardless of network participation:
"`SEC.
2706. NON-DISCRIMINATION IN HEALTH CARE.
`(a) Providers- A group health plan and a
health insurance issuer offering group or individual health insurance
coverage shall not discriminate with respect to participation under
the plan or coverage against any health care provider who is acting
within the scope of that provider's license or certification under
applicable State law."
<http://thomas.loc.gov/cgi-bin/query/z?c111:H.R.3590.eas:>
United States Supreme Court
ordered in
Kennedy v. Plan Administrator for Dupont, on January 26, 2009,
that the plan administrator must pay ERISA benefits to the party in
conformity of the plan document, instead of PPO or TPA guidelines.
ERISA provides no excuses or exceptions to the plan administrator’s
duty to act in accordance with plan document and participant
designation for whom the benefit checks should be sent to. The plan
administrators failure and refusal to send benefit checks directly to
the authorized and designated representative is judged by the plan
documents, including participant designation and legal assignment of
benefits. 29 U. S. C. §1132(a)(1)(B), a straight forward rule that
lets employers “ ‘establish a uniform administrative scheme, [with] a
set of standard procedures to guide processing of claims and
disbursement of benefits to the designated
and authorized representative. By giving a plan
participant, our patient as captioned above, a clear set of
instructions for making his own instructions clear, ERISA forecloses
the plan and your TPA from any justification for enquiries into
expressions of intent, in favor of the virtues of adhering to an
uncomplicated rule, ERISA claim regulations, rather than your TPA’s
personal opinions, PPO private contract or undisclosed protocols. Less
certain rules, such as your current noncompliant policies of
anti-assignment, could force plan administrators to examine numerous
external documents, such as TPA or PPO rules, purporting to be waivers
and draw them into litigations inevitably forthcoming over your
current practice of anti-assignment and refusal to comply with plan
participant unambiguous fiduciary instructions to send reimbursement
checks directly to health care providers clearly designated and
authorized by such plan participant or beneficiary.
SUPREME COURT OF THE
UNITED STATES
KENNEDY, EXECUTRIX OF THE ESTATE OF
KENNEDY,
DECEASED v. PLAN ADMINISTRATsOR FOR DUPONT
SAVINGS AND INVESTMENT PLAN ET AL.
CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE FIFTH CIRCUIT
No. 07–636. Argued October 7,
2008—Decided January 26, 2009
""2. Although Liv’s waiver was not
nullified by §1056’s express terms, the plan administrator did its
ERISA duty by paying the SIP benefits to Liv in conformity with
the plan documents. 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,’ ” Egelhoff v. Egelhoff,
532 U. S. 141, 148. By
giving a plan participant a clear set of instructions for making his
own instructions clear, ERISA forecloses any justification
for enquiries into expressions of intent, in favor of the virtues of
adhering to an uncomplicated rule. Less certain rules could force
plan administrators to examine numerous external documents
purporting to be waivers and draw them into litigation like this
over those waivers’ meaning and enforceability......."(Emphasis
added)
"disbursement of
benefits" = whom, how and where to send benefits checks to
Patient Protection and Affordable Care
Act, PPACA §2719, requires every group health plan to
comply with the established ERISA appeal process, 29 CFR, §2560.503-1:
“SEC. 2719. APPEALS PROCESS.
`(a) Internal Claims Appeals-
`(1) IN GENERAL- A group health plan and a health insurance issuer
offering group or individual health insurance coverage shall
implement an effective appeals process for appeals of coverage
determinations and claims, under which the plan or issuer shall, at
a minimum—
`(A) have in effect an
internal claims appeal process;
`(B) provide notice to enrollees, in a culturally and
linguistically appropriate manner, of available internal and
external appeals processes, and the availability of any applicable
office of health insurance consumer assistance or ombudsman
established under section 2793 to assist such enrollees with the
appeals processes; and
`(C) allow an enrollee to review their file, to present evidence
and testimony as part of the appeals process, and to receive
continued coverage pending the outcome of the appeals process.
`(2) ESTABLISHED PROCESSES- To
comply with paragraph (1)—
`(A) a group health plan and
a health insurance issuer offering group health coverage shall
provide an internal claims and appeals process that initially
incorporates the claims and appeals procedures (including urgent
claims) set forth at
section 2560.503-1 of
title 29, Code of Federal Regulations, as published on November
21, 2000 (65 Fed. Reg. 70256), and shall
update such process in accordance with any standards established
by the Secretary of Labor for such plans and issuers; and
`(B) a health insurance issuer offering individual health
coverage, and any other issuer not subject to subparagraph (A),
shall provide an internal claims and appeals process that
initially incorporates the claims and appeals procedures set forth
under applicable law (as in existence on the date of enactment of
this section), and shall update such process in accordance with
any standards established by the Secretary of Health and Human
Services for such issuers.” (Emphasis added)
<http://thomas.loc.gov/cgi-bin/query/z?c111:H.R.3590.eas:>
ERISA claim regulation has
outlawed since Jan. 01, 2003, the traditional anti-assignment practice
by the industry for 28 years and mandates the plan to send checks and
all information and documents to the provider who is properly
authorized representative on behalf of the patient regardless of
network participation:
PART 2560—RULES AND REGULATIONS FOR
ADMINISTRATION
AND ENFORCEMENT
§ 2560.503–1 Claims
procedure.
"(b)
Obligation to establish and maintain reasonable claims
procedures.
Every employee benefit plan shall establish and
maintain reasonable procedures governing the filing of benefit
claims, notification of benefit determinations, and appeal of
adverse benefit determinations (hereinafter collectively referred to
as claims procedures). The
claims procedures for a plan will be deemed to be reasonable
only if—
......
(4) The
claims procedures do not preclude an
authorized representative of a claimant from acting on behalf of
such claimant in pursuing a benefit claim or appeal of an
adverse benefit determination. Nevertheless, a plan may
establish reasonable procedures for determining whether an
individual has been authorized to act on behalf of a claimant,
provided that, in the case of a claim involving urgent care,
within the meaning of paragraph (m)(1) of this section, a health
care professional, within the meaning of paragraph (m)(7) of this
section, with knowledge of a claimant’s medical condition shall be
permitted to act as the authorized representative of the claimant;
...."
DOL ERISA FAQ's B3 clarifies
§2560.503-1 (b)(4) to mean that an ERISA plan should send
reimbursement checks directly the out-of-network providers who is
properly authorized by a patient regardless of network participation,
unless a patient instruct the plan not to. The decision to send the
check to which provider is from the patient, not the plan or PPO
opertors.
DOL FAQs About The
Benefit Claims Procedure Regulation
<http://www.dol.gov/ebsa/faqs/faq_claims_proc_reg.html>
"B-2: Does an assignment of
benefits by a claimant to a health care provider constitute the
designation of an authorized representative?
No. An assignment of benefits by a claimant is generally limited to
assignment of the claimant’s right to receive a benefit payment
under the terms of the plan.
Typically, assignments are not a grant of authority to act on a
claimant’s behalf in pursuing and appealing a benefit determination
under a plan. In addition, the validity of a designation of
an authorized representative will depend on whether the designation
has been made in accordance with the procedures established by the
plan, if any.
B-3: When a claimant has
properly authorized a representative to act on his or her behalf,
is the plan required to provide benefit determinations and other
notifications to the authorized representative, the claimant, or
both?
Nothing in the regulation precludes a plan from communicating with
both the claimant and the claimant’s authorized representative.
However, it is the view of the department that, for purposes of the
claims procedure rules, when a claimant clearly designates an
authorized representative to act and receive notices on his or her
behalf with respect to a claim,
the
plan should, in the absence of a contrary
direction from the claimant,
direct all information and
notifications to which the claimant is otherwise entitled to
the representative authorized to act on the claimant’s
behalf with respect to that aspect of the claim (e.g., initial
determination, request for documents, appeal, etc.).
In this regard, it is important that both claimants and plans
understand and make clear the extent to which an authorized
representative will be acting on behalf of the claimant."
As
President Barack Obama explained the new
PPACA and ERISA Appeals on Jan 09, 2010
in his weekly address:
”And there will be a new, independent
appeals process for anyone who feels they were unfairly denied a claim
by their insurance company.
In short, once I sign health insurance
reform into law, doctors and patients will have more control over
their health care decisions, and insurance company bureaucrats will
have less. All told, these changes represent the most sweeping
reforms and toughest restrictions on insurance companies that this
country has ever known.”
<http://www.whitehouse.gov/the-press-office/weekly-address-president-obama-outlines-benefits-health-reform-take-effect-year>
According to New York Attorney General
Andrew M. Cuomo on January 13, 2009, about
70% of
insured working Americans paid higher premiums for out-of-network
coverage and providers. It is a matter of national
economic social security for working American families if they will
get the benefit as promised, said Dr. Zhou.
“In February 2008, the Attorney General
announced an industry-wide investigation into allegations that health
insurers unfairly saddle consumers with too much of the cost of
out-of-network health care.
Seventy percent of insured working Americans pay
higher premiums for insurance plans that allow them to use
out-of-network doctors.
In exchange, insurers often
promise to cover up to eighty percent of the “usual and
customary” rate of the out-of-network expenses, and consumers are
responsible for paying the balance of the bill.”
<http://www.ag.ny.gov/media_center/2009/jan/jan13a_09.html>
New free webinars are a part of continued
efforts from ERISAclaim.com on a weekly and monthly basis to help all
involved with very specific and accurate statutory provision reviews
and discussions on all new Obama health law mandates for claim
appeals. The time for each free webinar is 60 minutes, from 11 AM to
12 PM, or 1 PM to 2 PM, Central Standard Time. Registration is free
for all. The Webinar Handout is also available and free to download
at: http://www.erisaclaim.com/Free_ERISA_Webnars.htm.
In the past 10 years, ERISAclaim.com has
been the only ERISA Specialized Company offering the most practical
and comprehensive ERISA education, consulting and publishing services
for healthcare providers in administrative ERISA appeals for real
problem oriented denials under the most mysterious 35-year-old federal
law, ERISA. Dr. Jin Zhou, president ERISAclaim.com has been regarded
as the Godfather of ERISA claims for healthcare providers by some in
Professional billing and coding industry.
ERISAclaim.com's
ERISA Appeal CD Book & Systems and Seminars Provide Complete Sample
Forms and Letters to Assistant Out-Of-Network Providers to Exercise
ERISA Rights, Including Right to Receive Reimbursement Checks Directly
From Payors.
For more information or to arrange an
interview, please contact Dr. Jin Zhou, president of ERISAclaim.com at
630-808-723 and ERISAclaim@aol.com or visit: <http://www.erisaclaim.com/Free_ERISA_Webnars.htm>
###
Contract:
Jin Zhou,
President
ERISAclaim.com
Tel:
630-808-7237 (Mobile)
Tel:
630-736-2974 (Office)
Fax:
630-736-1439
E-mail:
ERISAclaim@aol.com
website:
http://www.ERISAclaim.com
Related Links:
ERISAclaim.com: 50% Savings - Healthcare Crisis
Turnaround for Employers, Insurers & TPA's
ERISAclaim.com - A $1.0 Trillion Nuclear Solution
to U.S. Health-care Crisis & $44 Trillion Budget Deficits
American Benefits Council:
News Room - Supreme Court Ruling on Health Care Claims Raises Important
Policy Issues: American Benefits Council. June 21, 2004
"Sadly
and predictably trial attorneys and their allies are already calling on
Congress to unravel today’s decision by the Supreme Court, but they should
first ask why the two physicians in these cases did not act swiftly to help
make sure their patients got the care they were seeking.
In neither
case did the patient or their physician seek a further review of the health
plan’s initial coverage decision, despite being specifically informed of
their right to such a review under federal law."
Klein said."
"These
review procedures are available under ERISA
to help patients get the care they deserve, quickly and without having to
resort to costly and lengthy legal procedures. Clearly, a speedy and factual
review aided by the expertise of the physicians
involved with
these two cases could have avoided the need for the courts to be involved at
all,"
Klein said."
# # #
The American Benefits Council is the national
trade association for companies concerned about federal legislation
and regulations affecting all aspects of the employee benefits system.
The Council's members
