NU Online News Service, Sept. 23, 3:00 p.m. EDT

NEW YORK–Get ready for the Patient Protection and Affordable Care Act (PPACA) and all the uncertainties that go with it, including major Constitutional issues regarding the claims appeals process, according to a panel of legal experts here.

Rhonda D. Orin, managing partner of Anderson Kill & Olick (AKO) Washington D.C. office and a member of the firm's Insurance Recovery Group, was a speaker at the Anderson Kill & Olick Annual Policyholder Conference today. She noted that the new health reform law raises many Constitutional issues.

"It is impossible to imagine this won't be challenged straight to the Supreme Court," she said "That is the only place because it is a Constitutional issue."

The "holes" created by heath reform surface within the new rules regarding the internal and external claims and appeals process.

Whether an employee is the chief executive officer or the mail room clerk, appeals of claims will be handled by a contractually-paid, independent reviewer. Ms. Orin predicted the reform would spawn a "cottage industry of claims-deciding companies." This reviewer, paid for by the health plans, will gather evidence similar to a court of law and its decision is said to be binding.

Problems are expected to occur if a claimant chooses to go on to the federal external review process – which has yet to be developed, said Terry Connerton, Counsel to the law firm of Baker Hostetler, who was also on the panel.

"No one knows how the courts will give deference to contractually-paid deciders," Ms. Orin said. "This is a really big thing. What is the standard of review? What does binding mean?"

Certain mandates of the PPACA start Sept. 23, including the internal and external claims appeal procedures, with many more to come over the next several years on this date, said Ms. Orin.

Litigation also is likely to be generated by questions surrounding preemption, said Tess J. Ferrera, partner at Miller & Chevalier.

Sprinkled within the provisions, said Ms. Ferrera, is the declaration "that this is a floor" – that "if state law is more protective it is not preempted" and there is no distinction between self-funded and fully insured plans.

Certain group health plans are not subject to health care reform provisions and are considered grandfathered, Ms. Ferrera explained. However there are many ways to lose grandfather status, she noted.

"Many clients have given up trying to maintain grandfather status," she said. The status is applied to each benefit package and any change in the policy will end grandfather status, Ms. Ferrera continued.

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Constitutional Issues Loom For PPACA Claims, Appeals Process

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