New health care reform bill, The Affordable Health Care for American Act, was passed by the House of Representatives Saturday night, and is expected to be signed into law by President Obama by the end of the year. Provisions of the new law rely on the little understood ERISA law of 1974 which CRC is a unique, national, dedicated appeal processing expert.
Rockford, IL (PRWEB) Nov. 9, 2009 -- CRC, Claims Recovery Company, LLc, announced the expansion of its unique healthcare appeal services, following the House of Representatives passage the sweeping health care bill, H.R. 3962 representing the largest expansion of health care coverage since Medicare was created more than 40 years ago. President Obama said he was "absolutely confident" the Senate will follow suit in passing its version of the bill. Although turning the bill into law will see revision and Senate approval, it is now clear that claims regulations for reimbursement under this new federal law is based on ERISA and well settled from the bipartisan Bills. It will now be urgent for healthcare providers to take full advantage of ERISA regulation provisions.
"We have advocated since our inception, the use of federal ERISA law to resolve payment disputes with hospitals. We are thrilled that Congress agrees with us and hope that the Senate will too" Says F. Scott Winslow, CEO of the two year old CRC. "CRC has been utilizing the thirty four year old ERISA law and its claim regulations providing for a 'full and fair review' with a properly formatted, properly submitted ERISA appeal for its hospital clients from coast to coast."
Although it is currently uncertain what final provisions will be signed into law, the antitrust provisions of H. R. 3962 represent a sweeping opportunity for health providers to "level the playing field with the insurance industry through the new laws use of ERISA 29 CFR 2560.503-1, and equal anti-trust provisions for both insurers and providers for the first time. ERISA will be statutorily incorporated in its entirety into the new law for all qualified health benefit plans (QHBP), as the most important provisions from H. R. 3962 for healthcare providers for reimbursement purposes. The Affordable Health Care for America Act will create a new federal agency, Health Choices Administration, regulating qualified health benefit plans (QHBP), consisting of employment-based health plans, the traditional voluntary ERISA plans, and health insurance exchange plan, the new mandatory ERISA plans. The new legislation, H.R. 3962, is significant to CRC in following provisions:
1. Sec. 232 (b) of the Act, Requiring Fair Grievance and Appeals Mechanisms of the Act provides: "(b) INTERNAL CLAIMS AND APPEALS PROCESS.--Under a qualified health benefits plan the QHBP offering entity 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. 70246) and shall update such process in accordance with any standards that the Commissioner may establish". CRC is expert in this area and currently offers this service to existing clients.
2. Sec. 232 (c) of the Act also creates a new federal external review process based on ERISA claim regulation to provide for an impartial, independent, and de novo review of denied claims, and the Health Choices Commissioner's decision shall be binding on the plan and the entity, as the final claim decision in absence of judicial review, which will now be available for punitive damages for exchange participating health plans. CRC foresees an extended ability to assist clients as it has prepared files for this process since its inception under the existing regulation process.
3. Sec. 233 of the Act, Requiring Information Transparency and Plan Disclosure, enhanced the existing ERISA disclosure obligations for the plan and insurance company, and requires "Accurate and Timely Disclosure", for both exchange participating health benefit plans and employment-based health plans, to both the Health Choices Commissioner and the public, doctors, hospitals and the patients, of plan documents, plan terms and conditions, claims payment policies, and practices, periodic financial disclosure, data on the number of claims denials, data on rating practices, information on cost-sharing and payments with respect to any out-of-network coverage, and other information. CRC expects a more timely compliance with its ERISA based appeals and document reviews under this section of a new law.
4. Sec. 233 (5) of the Act, Cost-Sharing Transparency, requires the plan to disclose to the healthcare provider the real fee schedule, plan UCR limit for individual service and supplies at CPT & HCPCS code level. CRC foresees a distinct advantage in resolving its appeals on behalf of its clients the UCR provisions have been the most tightly held secrets of the insurance industry and subject to actions by attorneys' general.
5. Sec. 235 of the Act, Timely Payment of Claims, provides new federal "Prompt Pay" laws, based on Medicare Part C timeframe, Managed-Care Medicare, to comply with the requirements of section 1857(f) of the Social Security Act.
6. Sec. 238 of the Act, State Prohibitions on Discrimination against Health Care Providers, has adopted "Any Willing Provider Laws" from existing state laws. CRC sees a great advantage to it's out of network clients and predicts a new era of contracting with insurance companies for its hospital clients if this provision is written into the final version of the law.
7. Sec. 251 of the Act provides new consumer protections, with state law compensatory and punitive damages as remedies for exchange-participating health plan members. Although the new law does not change the status of ERISA preemption as desired by the insurance industry, state punitive damage remedies for employment-based health plans (traditional ERISA plans) will remain in effect.
8. Sec. 257 of the Act allows state attorney general to sue for the compensatory and punitive damages on behalf of the private citizen of the state for any violations by the exchange-participating health plans, although traditional ERISA plans are still immune from state government actions from insurance Commissioners or attorneys general.
9. Sec. 262 of the Act, Restoring Application of Antitrust Laws to Health Sector Insurers, if signed into law, this will cripple the existing managed care practice model and in conjunction with vigorous enforcement of the new provision for federal ERISA claim regulations, complete disclosure of plan information and fee schedules will now be mandatory under a proper ERISA appeal.
The Affordable Health Care for America Act is 1990 pages long. For more information and relevant documents, please visit the Website of House Of Representatives:
http://energycommerce.house.gov/index.php?option=com_content&view=article&id=1687&catid=156&Itemid=55
CRC offers, as an outside service, a process to appeal bad debt insurance claims (up to six years old) under federal ERISA law as a patient advocate. This has the potential to deliver substantial portions of the contractuals for any claim where the commercial insurance coverage was issued by an employer (government, church and a few other minor categories are accepted). CRC performs this "administrative appeal" process with no upfront fees and is paid a percentage of new payments delivered directly to the hospital. CRC's staff performs all work and answers all correspondence. CRC's approach has been utilized by hospitals and other providers for over ten years and they have clients from California to New York.
For more information or to arrange an interview, please visit www.crcclaim.com , or contact Mr. F. Scott Winslow, CEO at 815-397-8002.
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