Source: http://erisaclaim.com/Non_PPO_Checks.htm
Timestamp: 2017-02-19 11:48:17
Document Index: 215175741

Matched Legal Cases: ['§2719', '§2706', '§2560', '§2560', '§2706', '§1132', '§1056', '§1132', '§2719', '§2560', 'ART 2560', '§2560']

ERISAclaim.com - Health Reform for Out-Of-Network Providers: Receiving Insurance Checks Directly? – CD Books & Seminars on Why and How Non-PPO Checks?
Health Reform for Out-Of-Network Providers:
Receiving Insurance Checks Directly from an ERISA Plan? © JIN ZHOU, President, ERISAclaim.com
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.
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."
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.
DECEASED v. PLAN ADMINISTRATsOR FOR DUPONT
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)
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
"(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
(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-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."
”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>
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>