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New Federal Health Claims & Appeals Laws
&
Regulations
for 193 Million Americans
Effective 09-23-2010
©2010, Jin
Zhou, ERISAclaim.com |
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President
Obama Signing Health Bill on
03/23/2010
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President
Gerald R. Ford Signing ERISA on 09/02/1974 |
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New Webinars,
Seminars & Certification Classes Announced for New Federal Health
Claim Appeals Regulations on July 22, 2010 from HHS, DOL & IRS,
Effective On Sept. 23, 2010 for 193 Million Americans |
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UNITED STATES
DEPARTMENT OF LABOR
(Links to DOL)
©2010, Jin Zhou, ERISAclaim.com |
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Statutory Laws [PDF]
[PDF]
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Employee Retirement Income Security Act — ERISA |
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Webinars,
Seminars & Certification Classes for New Federal Health Claim Appeals
Regulations
ERISAclaim.com
- Free Webinars - New Federal Claims & Appeals Regulations, Effective
Sept. 23, 2010, for 193 Million Americans
ERISAclaim.com: Seminars - 2010 Two-day
Basic ERISA Appeal Seminars - Denials and Overpayment Appeals
ERISAclaim.com - 2010
PPACA & ERISA Claim
Specialist Certification Programs in Chicago, Illinois
ERISAclaim.com: Create An Appeal
Department for Your Hospital or Practice
(In-house, onsite ERISA Claim Specialist Certification Programs)
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950,000 MD's Settled
With Aetna & Cigna on ERISA
Rx-1
$$$$$$$$$ERISA $$$$$$$$$$
Rx-2
US
Supreme
Court Visits ERISAclaim.com
at 11:57:03 AM on Friday, November 21,
2003
Doctors fight Blues over fees - 09/10/04 (The Detroit News)
CMA Rebuts Health Plan
Allegations of Unfair Physician Billing Practices
[Posted
11/11/04]
Click here to download CMA's letter to
DMHC.
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Tort Reform, Fraud
& Healthcare Crisis? |
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New From Center for Justice &
Democracy:
***New Study*** Falling Claims and
Rising Premiums in the Medical Malpractice Insurance Industry
(July 7, 2005)
Appendix
News Release: New Study Leads
Attorneys General to Proclaim “No Excuse” and “A Matter of
Life and Death” (July 7, 2005)
PDF
"Joanne
Doroshow, Executive Director of the Center for Justice &
Democracy, which commissioned the report, stated, “To put it
bluntly, if you look at what the insurance companies say
about why they raise premiums, and then look at the data in
this report, thenumbers just don’t add up. The facts are
very simple: medical malpractice payouts are down yet
insurance companies have significantly increased premiums.
This shows that the
entire campaign to limit liability for doctors over the last
several years by capping compensation to injured patients
has been a fraud, and that based on these data, insurers
must know that it has been a fraud.”
Study Backgrounder (July 7, 2005)
PDF
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ERISAclaim.com - A $1.0 Trillion Nuclear
Solution to U.S. Health-care Crisis & $44 Trillion Budget
Deficits |
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Aetna +
CIGNA
Settlement
Demystified
© 2004 Jin Zhou, ERISAclaim.com
Settlements =
ERISA + 3
E. B.
Settlements =
ERISA + 3
E. B.
(Click
on each hyperlinks for details)
"Aetna
and CIGNA Settlement Secrets"(www.aetna.com)
Aetna ERISA "Talking
Points" (www.aetna.com) |
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ERISA stands for
Employee Retirement Income Security Act
-
E. B. = External Boards (of
Reviews) (§7.10-7.11):
1) Medical Necessity, 2)
Billing & Coding and
3)
Policy
Coverage
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Settlements
Only for
MCO/Provider Contract Disputes
-
Settlements
Not for
Patient Coverage/ERISA Disputes, (§7.10-7.11)
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Patient
Disputes =
ERISA/Coverage/Medical
Necessity/Bundling
& Down Coding
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Provider
Disputes =
PPO Discount/HMO Capitation/Provider Relationship
(DOL FAQ A8)
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Patient
Disputes
≠
Provider
Disputes, (DOL FAQ A8); Provider/MCO Contract
(PPO/HMO) Disputes are
not Triggered
until Patient
ERISA Disputes With the
ERISA Plan Are
100% Resolved or Moot (DOL FAQ C12)
(PASCACK VALLEY HOSPITAL, INC.
v LOCAL 464A UFCW WELFARE REIMBURSEMENT PLAN
(3rd Cir. 11/01/2004),
Northeast Hosp. Authority v. Aetna Health Inc.,
(October
17, 2007)
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External
Reviews (3 E. B.)
Are Not
Available until
Internal Reviews (ERISA) Completed,
(GAO)
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ERISA =
Federal Law Mandate;
External
Reviews
= State Law Mandate, (GAO)
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No
ERISA Compliance =
No Rights for Any One
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Title 29 U.S.C. § 1141 states:
"It shall be unlawful for any
person through the use of fraud, force, violence, or threat of
the use of force or violence, to restrain, coerce, intimidate,
or attempt to restrain, coerce, or intimidate any participant or
beneficiary for the purpose of interfering with or preventing
the exercise of any right to which he is or may become entitled
under the plan, this title, section 3001, or the Welfare and
Pension Plans Disclosure Act. Any person who willfully violates
this section shall be fined $10,000 or imprisoned for not more
than one year, or both. The amount of fine is governed by 18
U.S.C. § 3571. The U.S. Sentencing Guidelines address 29 U.S.C.
§ 1141 under the guidelines for "Fraud and Deceit" (U.S.S.G. §
2F1.1) or for "Extortion by Force or Threat of Injury or Serious
Damage (U.S.S.G. § 2B3.2)......"
"For example, Section 1141
would reach the use of deception directed
at misleading a welfare plan beneficiary as to the amount of
health benefits owed to the beneficiary under the terms of the
plan or at misleading a pension plan participant as to
the amount of retirement benefits to which he would become
entitled under the plan upon his retirement."
ERISA in the United States Code
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Breaking News
Are All
Consultants Corrupt? (Fast Company)
Did you know that
950,000
physicians nationwide have settled and agreed with Aetna and CIGNA in
their class-action lawsuit that 950,000 physicians must complete two
levels of ERISA appeals as health plans internal appeals for both ERISA
claims and non-ERISA claims before they can access the state protections
through state external review laws?
Did you know that 40 states
require the completion of
ERISA appeals by physicians or patients as
health plan internal appeals before anyone can claim state law
protections through state external review laws?
Ask your state association for more details on
how to complete ERISA appeals for your denied and delayed medical
claims.
A.
AETNA SETTLEMENT AGREEMENT (pdf, 97 pages), dated as of May 21, 2003 by and among AETNA INC., THE
REPRESENTATIVE PLAINTIFFS, THE SIGNATORY MEDICAL SOCIETIES AND CLASS
COUNSEL
"7.10. New Dispute Resolution Process for
Physician Billing Disputes.
a."......Nothing contained in this § 7.10 is intended, or shall be
construed, to supercede, alter or limit the rights or remedies otherwise
available to any Person under
§ 502(a) of ERISA or to supercede in any
respect the claims procedures of § 503 of ERISA."
[page 25]
7.11. Medical Necessity External
Review Process.
"(c) Notwithstanding
the provisions of § 7.11(a), Physicians
may not seek review of any claim for which the Plan Member (or his or
her representative) has filed suit under § 502(a) of ERISA. In
that event, or if such a suit is subsequently initiated, the Plan
Member’s lawsuit shall go forward and the
Physician’s claims shall be dismissed and may not be brought by or on
behalf of the Physician in any forum; provided that such
dismissal shall be without prejudice to any Physician seeking to
establish that the rights sought to be vindicated in such lawsuit belong
to such Physician and not to such Plan Member.
(d)
Nothing contained in this § 7.11 is intended, or shall be construed, to
supercede, alter or limit the rights or remedies otherwise available to
any Person under § 502(a) of ERISA or to supersede in any respect the
claims procedures under § 503 of ERISA.
e. Company shall maintain an internal
appeals process for medical necessity denials and shall disclose
such process on the Public Website. Company shall adjudicate all such
appeals of medical necessity denials on the timeframes that are
applicable to Plans
subject to ERISA, regardless of whether such
Plans are actually subject to ERISA......." [page 30]
Aetna Settlement Claim Form
(pdf)
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Aetna Reports First Quarter Results
HARTFORD, Conn.--(BUSINESS WIRE)--April 29, 2004--
"-- First-quarter operating earnings, excluding
favorable reserve development, of $1.75 per share, compared with
Thompson/First Call mean of $1.72, a 31 percent increase over
prior-year quarter
-- First quarter net income of $2.28 per share
-- Medical membership increase of 342,000 from
year-end 2003"
"We also announced several new initiatives to
reduce complexity for and improve communications with
physicians, including a new information resource, a billing
dispute mechanism, and dedicated service centers. And the
National Advisory Committee of Practicing Physicians, recently
formed as a direct result of our 'new era of cooperation'
agreement with physicians, held its first meeting."
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B.
CIGNA SETTLEMENT
(pdf, 150 pages )
(doc)
"7.10
Dispute Resolution Process for Physician Billing Disputes.
a. CIGNA
HealthCare shall implement an independent, external billing dispute
review process (the “Billing Dispute External Review Process”) for
resolving disputes with Class Members concerning the application of
CIGNA HealthCare’s coding and payment rules and methodologies to (i)
patient specific factual situations, including without limitation the
appropriate payment amount when two or more CPT® Codes are billed
together, or whether the Class Member’s use of modifiers is appropriate,
or (ii) any Retained Claims, so long as such Retained Claims are
submitted by the Physician to the Billing Dispute External Review
Process prior to the later to occur of either ninety (90) days after
Final Approval or thirty (30) days after
exhaustion of CIGNA HealthCare’s internal appeals process. Each
such matter shall be a “Billing Dispute.” The Reviewer (as defined
below) shall not have jurisdiction over any disputes that are not
patient specific application of Claim Coding and Bundling Edits,
including without limitation those disputes that fall within the scope
of the Medical Necessity External Review Process set forth in Section
7.11 of this Agreement, disputes about the submission of Clinical
Information that fall within the scope of Section 7.12, Compliance
Disputes and disputes concerning the scope of Covered Services.
Nothing contained in this Section 7.10 is
intended, or shall be construed, to supersede, alter or limit the rights
or remedies otherwise available to any Person under § 502(a) of ERISA or
to supersede in any respect the claims procedures of § 503 of ERISA.
"(3)
Time Limits for Completing Internal Appeals.
All internal
appeals shall be completed within the time limits required by
regulations issued by the Department of Labor, even those
internal appeals for which ERISA is not applicable.
[page 50]
(3) Notwithstanding the provisions of this Section
7.11, Class Members may not seek review of any claim for which the CIGNA
HealthCare Member (or his or her representative) has filed suit under §
502(a) of ERISA or other suit for the denial of health care services or
supplies on Medical Necessity grounds. In that event, or if such a suit
is subsequently initiated, the CIGNA HealthCare Member’s lawsuit shall
go forward and the Class Member’s claims shall be dismissed and may not
be brought by or on behalf of the Class Member in any forum; provided
that such dismissal shall be without prejudice to any Class Member
seeking to establish that the rights sought to be vindicated in such
lawsuit belong to such Class Member and not to such CIGNA HealthCare
Member. [page 52]
"(4) Nothing contained in
this Section 7.11 is intended, or shall be
construed, to supersede, alter or limit the rights or remedies otherwise
available to any Person under § 502(a) of ERISA or to supersede in any
respect the claims procedures under § 503 of ERISA."
[page 53]
Anti-balance Billing Instruction
to Non-participating Physicians (page 80-81)
"p. Participating Physician Status Dependent Upon Existence of
Contracts; Limitations on Obligations of Non-Participating Physician.
CIGNA HealthCare agrees that it will treat a Class Member as a
Participating Physician only in those circumstances in which the Class
Member is a party to a written contract with CIGNA HealthCare or with an
intermediary with which CIGNA HealthCare has a written contract. CIGNA
HealthCare further agrees that at least through the Termination Date, it
will not rent its networks to any other managed care company or health
insurer for the purpose of providing health care services or supplies to
any person who is not a CIGNA HealthCare Member; provided that nothing
in this sentence shall prevent CIGNA HealthCare from making its networks
available among the various current and future Subsidiaries of CIGNA
Corporation; and provided, further, that nothing in this sentence shall
be held to apply to a situation in which a CIGNA HealthCare customer
elects to make payments on claims in respect to provisions of health
care services or supplies to a CIGNA HealthCare Member through a third
party administrator or where CIGNA Behavioral Health provides mental
health services for another health insurance company or other entity. No
affirmative obligation that this Section 7 imposes on a Participating
Physician shall apply to Non-Participating Physicians unless and until,
and then only to the extent that, with regard to each individual claim,
such Non-Participating Physician submits or transmits to CIGNA
HealthCare a claim for payment which designates therein that the
Non-Participating Physician has accepted an Assignment of the CIGNA
HealthCare Member’s benefits as payment for that individual claim.
q. Effect of Assignment of Benefits.
The existence of an Assignment of Benefits authorization, whether or not
submitted by the Non-Participating Physician to CIGNA HealthCare,
does not constitute in and of itself full or
partial payment of the Non-Participating Physician’s fee (unless so
agreed between the Non-Participating Physician and the CIGNA HealthCare
Member), does not create an implied contract between the
Non-Participating Physician and CIGNA HealthCare, and does not limit the
Non-Participating Physician’s fee to any fee schedule. The
Non-Participating Physician retains the right to elect either to collect
the Non-Participating Physician’s full fee from the CIGNA HealthCare
Member or collect partial payment from CIGNA HealthCare and the balance
from the CIGNA HealthCare Member (“balance bill”)."
C.
Both Aetna and CIGNA have agreed to
settle the class-action lawsuits by 950,000 physicians and agreed to
process appeals in accordance with
ERISA claim regulations for both ERISA claims
and
non-ERISA claims, and to establish external review
boards for
Billing and Coding Disputes,
Medical Necessity Disputes and Policy Coverage Disputes, in
compliance with state external review laws, however external reviews
will not be available until internal appeals/ERISA appeals are
completely exhausted.
D.
950,000 physicians agreed to complete
ERISA appeals to Aetna and CIGNA with 100% of the claims
for both ERISA claims and
non-ERISA claims, instead of
80% of
claims under
ERISA
plans, and
to complete
ERISA appeals to Aetna and CIGNA
in all 50 states instead of
40 states where state
law requires exhaustion of health internal appeals process before
seeking for external review under state laws for
Billing and Coding Disputes,
Medical Necessity Disputes and Policy Coverage Disputes.
E.
All other 8 major insurance companies named in class-action lawsuit have
refused to settle,
even if federal court would rule for physicians, the Aetna and CIGNA
settlements will be as good as it could get from the rest of insurers
and MCO's as evidenced in Aetna and CIGNA settlements with physicians.
F.
Unless physicians understand and
complete ERISA internal appeals, all of
those
"a love fest" and
"victories" from class-action settlements would mean a fantasy of
"a love fest" to any
physicians.
"Forty
states required individuals to first exhaust their health policy’s
internal appeals and grievance process before seeking external review."
According to United States General Accounting
Office (GAO) Report to Congressional Requester, dated September 2003,
Page 46.
The health policy’s internal appeals and grievance process =
ERISA appeals for
80% of the
health claims.
Judge approves $540 million Cigna settlement with doctors
950,000
Physicians Agreed to Do ERISA Appeals
in
Settlement of Physician Class-Action Lawsuits
Judge Approves Aetna Settlement (CNN, 10/25/03)
"Aetna
and CIGNA Settlement Secrets"
"Talking
Points"
What You
Should Know about Filing Your Health Benefits Claim
Court Approves
Settlement between Cigna and 700,000 Physicians (HMOcrisis.com)
AMA
SUPPORTS CIGNA SETTLEMENT WITH NATION’S PHYSICIANS
State of Connecticut v.
Health Net, Inc.,
11th Cir. 09/10/2004
State Can NOT Enforce ERISA,
Publicly or Privately
(ERISAclaim.com -
Managed Care Court Watch)
Hawaiian Court Reverses Lower
Court Ruling on ERISA Preemption of State Law on External Review
(The Supreme Court of the State of Hawaii)
Excerpt: "The Hawaiian Supreme Court ruled November
18, 2004, that a state law that gives Hawaii's insurance commissioner
authority to conduct external reviews of health insurance plan
decisions is 'impliedly' preempted by the Employee Retirement Income
Security Act (ERISA)."
California
SB 1569/Knox-Keene Act, "Allowing
Physicians to Sue Health Plans for Fair Payment",
Will be Preempted by ERISA
(Copyright © 2004
by
Jin Zhou,
ERISAclaim.com)
08/30/2004
"The article is to
explore whether the Employee Retirement
Income Security Act of 1974 (ERISA), 88 Stat. 832, 29
U. S. C. §1001 et seq., pre-empts
California
"SB 1569"/Knox-Keene Act
to the
extent it applies to ERISA plans.
I believe
it does, in accordance with the Supreme Court ruling for both
Egelhoff
v. Egelhoff
and
Aetna
Health Inc. v. Davila."
HMOs Earn $10.2 Billion in 2003,
Nearly Doubling Profits, According to Weiss Ratings; Blue Cross Blue
Shield Plans Report 63% Jump in Earnings
(BUSINESS WIRE)--Aug. 30, 2004
Class-Action Status Is
Upheld for Doctors Suing Insurers
(The
New York Times)
"An appeals court upheld class-action status
yesterday for a lawsuit brought on behalf of at least 600,000 doctors
contending that six of the nation's largest health insurers regularly
reduce payments for medical services."
Eleventh Circuit Court of Appeals
Affirms Class Certification for RICO Lawsuit Filed by the Nation’s
Doctors Against Leading HMOs (hmocrisis.com)
"Plaintiff’s
Lead Counsel Archie Lamb: Largest Physician Led Class Certification in
Federal Court History Has Now Been Affirmed
Wednesday
September 1, 2004: The Eleventh Circuit Court of Appeals issued a
sweeping decision today affirming class action certification in the
landmark RICO case filed to combat widespread and chronic abuses by
some of the nation’s largest for profit HMOs."
"Blue Cross Blue Shield
Lawsuit
On January 5, 2004, the North Carolina Medical Society filed a
lawsuit against Blue Cross Blue Shield of North Carolina in
Wake County Superior Court
.....
As in the Aetna and CIGNA lawsuits, we are
asking for prospective relief in the form of substantial
changes in BCBSNC's business practices."
Jun
25, 04 Joint Tag-Along Status Report (Donald S. Horener, MD, et al v.
BCBS of North Carolina) /Appendix:
(Complaint) Part 1 /
Part 1 (hmocrisis.com)
"JOINT TAG-ALONG STATUS REPORT
Pursuant to the Notice of Court Practice in MDL Tag-Along Actions and
Order Closing Case for Statistical Purposes and Placing Matter in a
Civil Suspense File dated May 27, 2004 (the "May 27 Order"), the parties
submit the following report regarding the status of Donald S. Homer,
MD., et al. v. Blue Cross Blue Shield of North Carolina, which was filed
in the Superior Court Division for the County of Wake, General Court of
Justice of North Carolina on January 5, 2004,
removed to the United States District Court
for the Eastern District of North Carolina, Western Division, on
February 5, 2004, and transferred to Judge
Moreno on May 24, 2004, pursuant to MDL
Rule 7.4."
Jun
25, 04 Joint Tag-Along Status Report (North Carolina Medical Society v.
BCBS of North Carolina) /
Appendix (Complaint) (hmocrisis.com)
"1.B. The Nature of the
Defenses Asserted by the Defendant
Defendant asserts that Plaintiff lacks standing to bring this action on
behalf of itself or its members. Defendant further asserts that
Plaintiff's state law claims are preempted by the
Employment Retirement Income Security Act of 1974, as amended ("ERISA"),
29 U.s.c. § § 1001, et seq.; and by the Federal Employee Health
Benefits Act, as amended ("FEHBA"), 5 U.S.C. §~ 8901, et seq."
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U.S. Health-care Crisis & ERISA Criminal Enforcement
|
"New
Strike Force" |
Medical Fraud Every Day?
Appeal or Re-Bill After
Denial?
You Must APPEAL
No Re-Billing!!!
Claim Appeal or
Sentencing Appeal?
Your Choice
Maximal Reimbursement
through ERISA Appeal &
Fraud Prevention and
Compliance
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Aetna:
Leading the Fight Against Health Care Fraud
[PDF]
View as HTML
"Thanks to this highly collaborative
relationship, we know how to identify fraud because we know
what to look for.
Medical Fraud
-
Unusual provider
billing practices.
Discrepancy between
the submitted diagnosis and the treatment.
Diagnoses or
treatments that are outside the practitioner’s scope of
practice.
Claims that are
resubmitted with coding changes to gain benefits.
Alterations on claim
submissions.
Pressure for quick
claim payment."
Payments Go Under a Microscope (washingtonpost.com)
January 12, 2004
"MAMSI and CareFirst
recoup overpayments to
doctors by making deductions from future reimbursements.
Doctors can appeal insurers'
decisions. But, in the end, they usually pay up, doctors
and insurers agree."
Employers Audit Workers' Health Claims (Wall Street
Journal via SFGate.com)
Excerpt: "Looking to bring down soaring
health-care costs anywhere they can, more employers are scouring
their health plans for fraud, abuse and simple mistakes by
employees or administrators.
.......The
number of requests for such audits jumped 50 percent last year,
Mr. Farley estimates."
Clinton Township Firm Convicted of
Overbilling (Macomb
Daily)
"The case is somewhat
unusual in that a corporation was named as a criminal defendant
in the case,
but Kaiser said that is not unheard of since corporate law can
make a firm liable for criminal wrongdoing, and its principal
office holders in return are responsible for any judgments or
punishments the courts impose.
David Griem,
the defense attorney for Emergency Management who was also named
the principal to enter a guilty plea on its behalf,
also could not be reached for comment after the sentencing
hearing. In court, however, he turned over a check to the Blue
Cross insurance company officials in attendance and said the
company would pay the $5,000 court costs on time as well."
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Health Care Fraud Report
Fiscal Year 1998
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USDOJ: Deputy Attorney
General: Publications and Documents - - Health Care Fraud
Report Fiscal Year 1998
"On June
4, 1998, in the District of Maryland, Levindale Geriatric
Hospital paid $800,000 to resolve allegations it violated
the FCA by recoding and resubmitting
denied charges for room and board. After the claims for room
and board were denied by the Medicare Part A program,
Levindale recoded the claims as supplies, laboratory work
and other services, and submitted the claims for payment.
In addition to paying a substantial penalty under the FCA,
Levindale entered into a compliance agreement with HHS-OIG"
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Who Can Be a Medical Reviewer under ERISA?
(Copyright © 2004
by
Jin Zhou,
ERISAclaim.com)
U.S.
SUPREME COURT
Docket for 03-83
ORAL ARGUMENT TRANSCRIPTS (page
46 0f 49)
| 02-1845.
Aetna Health Inc. v. Davila |
03/23/04 |
"QUESTION: Mr.
Estrada, you can address what you would like but there are three
points that have come up during the Respondent's presentation
that I'd be interested with a response to.
Number one, is it true
that the people who make the decisions for your client must be
medical doctors in Texas?
MR. ESTRADA:
Well it is true by virtue of DOL regulations which provide that
no claim may be turned down without input from a medical
professional in the relevant area"
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New
Federal Claim Regulation (Final Rule)
-
"Plans must
consult with
appropriate health care
professionals in
deciding appealed claims
involving medical judgment."
[70268-70269,
CFR § 2560.503-1(h)(3)(iii)]
-
"The term `health care professional' means a
physician or other health care professional
licensed, accredited,
or certified to perform specified health
services
consistent with State law." [page
70271
CFR § 2560.503-1(m)(7)]
-
"medical doctors in Texas"
=
MD licensed to practice medicine in Texas
for a Texas ERISA case;
-
"a medical professional in the
relevant area" = relevant area of state laws in license
jurisdiction, scope of practice and relevant local standard of care;
-
"licensed"
= licensed by the State Government/licensing board;
-
"to
perform"
= to practice medicine or health care services in the
State;
-
"specified
health services"
= medical procedures or services being reviewed or denied, instead of
file review or insurance coverage reviews
services;
-
"consistent with State law"
= consistent with State laws where the health care professional is
legally licensed to practice medicine or health care services with
respect to state jurisdictions, scope of license and state local
medical standard of care.
"The term `health care professional' means, in layman term, a
physician or other health care professional who is at least licensed in
your state (and more, board certified too) to practice the
specified/specific health services being reviewed or denied of your
claims, consistent with your state law jurisdiction, scope of practice
and local medical standard of care. Someone who is not licensed to
practice the same health care services specified/denied in your claims
is not qualified as an "appropriate health care
professionals" as defined under ERISA
§ 2560.503-1(m)(7).
Someone who is not licensed in your state to
practice "specified health services" but who is merely registered under
state or other means (URAC, IME, SSD or Peer Reviews) to do Utilization
Reviews (UR)
is not qualified as an "appropriate health care
professionals" as defined under ERISA
§ 2560.503-1(m)(7).
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NEW Utah State law
Mandates ERISA Claim Regulation
(Copyright © 2004
by
Jin Zhou,
ERISAclaim.com)
Did you
know that, effect on
March 1, 2004,
a NEW Utah State law,
UT Admin Code R590-203. Health Grievance Review Process and
Disability Claims., has mandated every health insurer and
HMO conducting business in the State of Utah to comply with ERISA claim
regulation, regardless if the plan is actually an ERISA plan.
This is the first state law for health insurance and manage care that
mandates and clones ERISA claim regulation at state-level. More and more
states are expected to follow.
UT Admin Code R590-203. Health Grievance Review
Process and Disability Claims.
"R590-203-2.
Purpose.
The purpose of this rule is to ensure that health insurer's
grievance review procedures for individual and employer health benefit
plans comply with the Department of Labor, Pension and Welfare Benefits
Administration Rules and Regulations for Administration and Enforcement:
Claims Procedure, 29 CFR 2560.503-1, Utah Code Sections 31A-4-116 and
31A-22-629."
(Bulletin)
(Utah
Code Section 31A-22-629)
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00-MD-1334-MORENO - In RE: Managed Care
Litigation
Order granting
plaintiffs' motion for preliminary injunction*
(12/12/2002)
Order granting
provider track class certification and denying subscriber track class
certification* (09/26/2002)
Aetna Settlement
Approval
October 24, 2003,
To view a copy of the Orders
-
Order 1
|
Order 2
CIGNA
Healthcare Announces Settlement of Physician Class-Action Lawsuits,
Sep 3, 2003
(Cigna.com)
CIGNA SETTLEMENT (HMOcrisis.com)
Aetna Reaches Agreement with
Physicians, May 22, 2003
(Aetna.com)
Aetna Settlement Claim Form
(pdf)
CMA Settles with Aetna in
Class Action Lawsuit
A Summary of the Settlement
Agreement Prepared by CMA Attorneys
(calphys.org)
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What's
???
??? ???
New
??
?
New Federal Claim
Regulation (Final Rule)
Benefit
Claims Procedure Regulation (FAQ)
Amendments to Summary Plan Description Regulations
(Final Rule)
Patient's Rights Claims Procedure Regulation
(Fact Sheet)
What You
Should Know about Filing Your Health Benefits Claim
Effective January 01, 2003
You
Must Be in Compliance
|
Brief Summary Of
the
New Regulation
for Physicians and
ERISA Plans/TPAs |
|
Effective Date: January 01, 2003 |
|
For
Physicians and Health-care Providers |
For
Insurance Companies
ERISA Plans/TPAs |
|
ERISA's
Prompt Pay Law, better than State Prompt Pay Laws
[29 CFR § 2560.503-1
(f)(i),
Page 70267-9] |
ERISA's
Prompt Pay Law, better than State Prompt Pay Laws
[29 CFR § 2560.503-1 (f)(i), Page 70267-9] |
|
|
|
|
New Assignment of Benefit Form Required for
Appeals and Claim Dispute
(DOL
FAQ, B2-B3) |
No New Legal Assignment of Benefit Form, No
Obligations to Physicians and Health-care Service Providers
(DOL
FAQ B2),
otherwise Obligations to Disclose to Both Patients and Providers
(DOL FAQ B-3) |
|
|
|
|
No written appeal, no rights, except for claims
involved with urgent care.
[Page 70255 & 70271] |
In claims involved with urgent care,
physicians/health-care providers are to be considered by default as
authorized representatives.
[Page 70255 & 70271] |
|
|
|
|
The regulation clarifies for the first time since 1977 and
prohibits anti-assignment provisions in ERISA plans & (footnote 36).
[page 70255 ]
[29 CFR § 2560.503-1 (b) (4) Page 70266] |
Assignments by patients must be absolutely
clear as to what extent and capacity, verifications are permitted &
(footnote 36).
(DOL FAQ B-3)
[page 70255 & 70266]
[29 CFR § 2560.503-1 (b) (4), Page 70266] |
|
|
|
|
Must complete required two levels of appeals,
with legal assignment of benefits and specific written request for
disclosure of specific plan documents.
[Page 70253] |
No legal assignment of benefits, no response
required; no specific written request, no disclosure obligated,
however failure to establish and comply with claim procedures,
administrative remedies are considered to be exhausted. Lawsuit may
follow.
[Page 70271] |
|
|
|
|
New protections for pre-service claims and
urgent care claims against improper pre-authorization,
pre-certification and utilization review as well as urgent cares.
[Page 70248 & 70271] |
Understanding of differences in pre-service,
urgent care and post-service claims will save big money in fiduciary
breach liability claims and
POSSIBLE
medical malpractice claims. [Page
70248 & 70271] |
|
|
|
|
New definitions of relevant documents and
disclosure obligations, no more medical necessity secrets, UCR fee
schedule confidential
[Page 70252]
[29 CFR § 2560.503-1 (h)(2)(iii) (m) (4), Page 70268, 70271]
[DOL FAQ B-5] |
No legal assignment of benefits, no obligation
to disclose to an assignee, assignment verification by the plan is
allowed and protected.
Update SPD and any guidelines, only use disclosable and
qualified medical claim reviewers.
[Page 70252]
[29 CFR § 2560.503-1 (h)(2)(iii) (m) (4), Page 70268, 70271]
[DOL FAQ B-5] |
|
|
|
|
A Full and Fair Review with new definitions and
protection requires de novo reviews on two appeals by at least four
different people, two different fiduciaries with ERISA plan, and
two different Health-care professionals independent to the ERISA
plan.
[29 CFR § 2560.503-1 (h) (3)(ii)(iii)(iv)(v), Page 70268-9, (m) (8), Page 70271]
[Page 70252-70253] |
Update
SPDs with New Standards and compliance, specify and designate
only qualified fiduciaries for appeals, establish new complaint
appeal procedures, use only disclosable and licensed as well as
certified health-care professionals for medical reviews,
pre-certification and prior authorizations in every case.
[29 CFR § 2560.503-1 (h) (3)(ii)(iii)(iv)(v), Page 70268-9, (m) (8), Page 70271]
[Page 70252-70253] |
|
|
|
|
New clarifications on state law preemptions and
"independent" medical reviews. No preemption for state laws unless
prevention of the application of the new regulation
[Page 70254] |
Comply with both
the regulation and state laws in claims involving mixed
treatment and eligibility determinations and pure medical treatment
decision-makings.
[Page 70254] |
|
|
|
|
New clarifications with new definitions claim
denial/an adverse benefit determination (payment<100% claimed)
or Overpayment, and new protections.
(DOL FAQ C-12) |
Overpayment vs. an adverse benefit
determination, recoupment vs. appeal procedures.
(DOL FAQ C-12) |
|
|
|
|
SPDs must
describe...... |
No SPDs, No
decision making |
|
|
|
|
Insurance company's decision-making power and
disclosure obligations must be described in SPD
[29 CFR 2520.102-3 (q), Page 70242] |
Fully-insured plans with a health insurance
issuer being wholly or partially responsible for administering the
plan (e.g. payment of claims) must describe insurer's role in SPD.
[29 CFR 2520.102-3 (q), Page 70242] |
|
|
|
|
Claim fiduciary, whoever makes denial
appeal decisions, has duties to disclose
SPD and relevant document
[29 CFR § 2560.503-1 (h)(2)(iii), (3)(iii) Page 70268-9, (m) (8), Page 70271] or may face up to $110 a day penalty under "Prudent Actions by Plan
Fiduciaries" and "Enforce Your Rights."
[29 CFR § 2520.102-3, Page 70243] |
Claim fiduciaries or plan fiduciaries
have new duties to disclose, without charge,
SPD and relevant
document
[29 CFR § 2560.503-1 (h)(2)(iii), (3)(iii) Page 70268-9, (m) (8), Page 70271] when claim for
benefits is denied or delayed, or may face up to $110 a day penalty
under "Prudent Actions by Plan Fiduciaries" and "Enforce Your
Rights."
[29 CFR § 2520.102-3, Page 70243] |
|
Failure to timely
make benefit determination and review decisions by the plan
administrator will constitute "deemed denied" review/appeal and
"deemed exhaustion of administrative remedy" under
§ 2560.503-1(l), ("a decision on the
merits of the claim" = de novo judicial review, instead of
deferential judicial review) that will forfeit or preclude
the plan from "deferential review standard" on judicial review in
federal court,
the most important part of "ERISA Shield" on ERISA land.
Gilbertson v Allied Signal Inc |
DOL interprets
§
2560.503-1(l) through CFR accompanying supplementary information on
page 70255: “The Department’s intentions in including this
provision in the proposal were to clarify that the procedural
minimums of the regulation are essential to procedural fairness and
that
a
decision made in the absence of the mandated procedural protections
should not be entitled to any judicial
deference.” |
|
More.... |
More.... |
More.... |
|
And
many more new and
important
provisions and protections for health-care providers and
insurance companies/ERISA plans/TPA's, as well as patients and
employers. |
|
|
|
|
Denials +
Recoupment =
Inflation +
fraud or
Cost-Sharing?
Rx =
Compliant Denial & Appeals! |
|
Forbes.com: "Roughly one in seven Americans has
no health insurance. That hurts HCA Inc. (nyse:
HCA -
news
-
people), the largest U.S. hospital chain, which
last year wrote off $2.21 billion
of revenue because patients couldn't pay their
bills."
The American Hospital Association (AHA): "Hospitals today are faced with the challenge of managing their
limited resources, while continuing to deliver the highest standard of care.
According to health care experts, the cost of clinical
denials to individual healthcare organizations averages
$3.3 million
annually. However, many hospitals do not have the resources or the
expertise needed to avoid unpaid days at the end of admissions and lead the
denial-appeals processes."
Payments Go Under a Microscope (washingtonpost.com)
"MAMSI and CareFirst recoup overpayments to doctors by making
deductions from future reimbursements.
Doctors can appeal insurers' decisions.
But, in the end, they usually pay up, doctors and insurers agree."
Hospital Pricing and the Uninsured,
Glenn Melnick, Ph.D.,
"Price
Gouging"
(Subcommittee on Health
Hearing on the Uninsured,
U.S.
FILES COMPLAINT AGAINST NATIONAL ACCOUNTING FIRM UNDER FALSE CLAIMS ACT
(DOJ
Press Release) "January 5, 2004
- PHILADELPHIA –
United States Attorney Patrick L. Meehan announced today the filing of the
Government's
complaint against national accounting firm Ernst & Young.
According to the complaint, nine hospitals paid Ernst & Young for billing
advice – advice which later caused the submission of false claims to the
Medicare program."
USATODAY.com - Hospitals Sock Uninsured with Much Bigger Bills
GM to Report $60B in Future Health-Care Obligations
|
|
|
New Federal Claim
Regulation (Final Rule)
After a
one year
delay,
New
Federal Benefit Claims Procedure Regulation has become
effective
January 01, 2003 for almost all of the
private group health plans. It will affect
about
80% of
health-care claims or
60% of health expenditures,
approximately
6 million private health and welfare plans and approximately 150 million
workers and their dependents
in the U. S..
|
|
|
|
"The
regulation will affect
participants and beneficiaries of employee benefit plans,
employers who sponsor employee benefit plans, plan fiduciaries, and others
who assist in the provision of plan benefits, such as third-party benefits
administrators and
health service providers or
health maintenance organizations that provide benefits to
participants and beneficiaries
of employee benefit plans." |
|
|
|
The
Regulation is the
most significant change
in health-care laws since 1977, and it has been considered by
congressional leaders to be more powerful than proposed Patients Bill Of
Rights. "The
regulation establishes
new standards for the processing of
claims under group health plans and plans providing disability benefits and
further clarifies existing standards for all other employee benefit plans.
The new standards are intended to ensure
more timely
benefit
determinations, to improve access to information on which a benefit
determination is made, and to assure that participants and
beneficiaries will be afforded
a full and fair review of denied
claims."
|
|
|
|
Contrary to the popular belief, the
new federal claim regulation provides
more
protections for
physicians and patients than
state insurance and
Prompt Pay Laws, and more protections and clarifications for
insurance companies and the ERISA plan sponsors as well as the third
party benefits administrators than state laws in punitive damages as
proposed in Patients
Bill Of Rights.
However,
failure to understand and comply timely
with
the
regulation will invite and suffer from unanticipated financial
and legal consequences.
AMA has finally noticed the existence and effective date of this
new
federal claim regulation, as described in its
January 20, 2003 online edition of American Medical News: "Federal
regulations that dictate rapid turnaround times for health plan claims
and appeals quietly went into effect this
month, with little noise from the managed care industry."
However AMA has failed,
as it did in past 28 years,
to practically and meaningfully understand
the
ERISA
and its
significance as protections for
health-care providers, entire industry has failed to offer any
educational programs and
occupational trainings to health-care
providers in this most important
federal law and regulation that
governs and regulates
up to
80% of
health-care claims and
60% of
U.S. healthcare expenditures.
As reported by AMA as to the time it may take for
this
new federal claim regulation to take effect in marketplace,
Jeffery Mandell, president of the ERISA Law Group in Boise, Idaho,
states "it often takes years, even decades, for the marketplace to fully
adopt new regulations".
Life is too short, our nation's health-care system is going through
the
worst crisis since World War II and can't afford another 28 years to
realize and implement the
ERISA
regulations. We, everyone including health-care providers,
legislators, regulators and
insurance companies and TPA's, should take
immediate actions to educate everyone in the system and to implement
this new
federal claim regulation as we are fighting against terrorists to
save our nation's
health-care system from worse-than-terror-war crisis.
The latest Harvard & RAND study for Congress and state legislative debate on Patients'
Bills of Rights, conducted by David Studdert and Carole Roan Gresenz,
study authors from the Harvard School of Public Health and RAND, funded
by federal government, Department Of Labor, and Agency for Health Care
Research and Quality, revealed that
"little is publicly known about such appeals system", and concluded
that "A
majority of preservice appeals disputed choice of
provider or contractual coverage issues, rather than medical necessity.
Medical necessity disputes proliferate not around life-saving treatments
but in areas of societal uncertainty about the legitimate boundaries of
insurance coverage. Greater transparency about the coverage status of
specific services, through more precise
contractual language and consumer education about benefits limitations,
may help to avoid a large proportion of disputes in managed care."
A
JAMA Editorial commenting this study further supported the
conclusion of this study and advanced the
right solutions
more precisely at
New
ERISA Claim Regulations: "Regulations
issued by the Clinton administration in 2000
were designed to infuse rigor into the appeals process maintained by
employer-sponsored health plans covered by the Employee Retirement
Income
Security Act (ERISA),10 which governs insurance arrangements
for more than 150 million workers and their family members. Whether
these rules will be vigorously enforced remains to be seen."
This valuable study has pointed out the direction but failed to provide
a turnkey practical solution.
ERISAclaim.com has provided this nation with a turnkey operational
solution with ERISA compliance, to educate
everyone on ERISA, coverage and
claim
procedures, to ensure "Bill Of Rights" for Patients, Providers, Plan
Sponsors and Insurers.
Aetna
(DOL/ERISA),
First Health,
Blue Cross Blue
Shield are ready to comply with new federal regulation (BCBSIL) (BCBSMI)
(BCBSCNY)
(BCBSNE)
(CareFirstBCBS)
& (BCBSAL), are
you ready to get paid
faster and fairer?
From
Aetna's ERISA yesterday (Aetna Video Shows ERISA
Patients Mistreated) to
Aetna's ERISA today
(DOL/ERISA) =
Aetna ERISA
Actions or intention in compliance and in
control.
From
AMA's ERISA
yesterday (The latest Harvard & RAND study)
to
AMA's ERISA today (JAMA Editorial)
=ERISA Actions or Not?
That's why physicians, healthcare
providers and hospitals must
wake up on ERISA
now!
"Forty
states required individuals to first exhaust their health policy’s internal
appeals and grievance process before seeking external review." (GAO,
September 2003, Page 46) The health policy’s internal appeals and
grievance process =
ERISA
appeals 80% of the time.
"Congress
library report", "Minneapolis
memorandum" and "Phoenix
memorandum"
should have been sufficient
intelligence for executive
decision-making on
health-care
Oct. 11
fact card.
The
Latest AMA (PSA) Managed Care Hassles Survey through nationwide state
medical associations and national medical specialty societies identified
the most popular and important managed-care claim denials and delays.
|
Top Seven Issues through
National Medical Specialty Societies |
|
Rank |
Problems Reported By
Popularity Rank |
% |
|
1 |
Bundling |
67% |
|
2 |
Medical Necessity Decision
Denials |
43% |
|
3 |
Prompt Payment |
43% |
|
4 |
Administrative Hassles |
33% |
|
5 |
Coding Issues |
24% |
|
6 |
Downcoding |
19% |
|
7 |
Bargaining Lack of
Negotiation Power |
14% |
|
Top Eight Most Importantly & Frequently Listed
Issues through
State Medical Associations |
|
Rank |
Problems Reported By
Importance Rank |
|
1 |
Downcoding & Bundling |
|
2 |
Prompt Payment |
|
3 |
Lack of Budgeting Power |
|
4 |
Medical Necessity Denials |
|
5 |
Prior Authorization of
Med. Services |
|
6 |
Health Plan Credentialing |
|
7 |
Drug Formularies |
|
8 |
Other |
|
|
Brief Summary Of
the
New Regulation
for Physicians and
ERISA Plans/TPAs |
|
Effective Date: January 01, 2003 |
|
For
Physicians and Health-care Providers |
For
Insurance Companies
ERISA Plans/TPAs |
|
ERISA's
Prompt Pay Law, better than State Prompt Pay Laws
[29 CFR § 2560.503-1
(f)(i),
Page 70267-9] |
ERISA's
Prompt Pay Law, better than State Prompt Pay Laws
[29 CFR § 2560.503-1 (f)(i), Page 70267-9] |
|
|
|
|
New Assignment of Benefit Form Required for
Appeals and Claim Dispute
(DOL
FAQ, B2-B3) |
No New Legal Assignment of Benefit Form, No
Obligations to Physicians and Health-care Service Providers
(DOL
FAQ B2),
otherwise Obligations to Disclose to Both Patients and Providers
(DOL FAQ B-3) |
|
|
|
|
No written appeal, no rights, except for claims
involved with urgent care.
[Page 70255 & 70271] |
In claims involved with urgent care,
physicians/health-care providers are to be considered by default as
authorized representatives.
[Page 70255 & 70271] |
|
|
|
|
The regulation clarifies for the first time since 1977 and
prohibits anti-assignment provisions in ERISA plans & (footnote 36).
[page 70255 ]
[29 CFR § 2560.503-1 (b) (4) Page 70266] |
Assignments by patients must be absolutely
clear as to what extent and capacity, verifications are permitted &
(footnote 36).
(DOL FAQ B-3)
[page 70255 & 70266]
[29 CFR § 2560.503-1 (b) (4), Page 70266] |
|
|
|
|
Must complete required two levels of appeals,
with legal assignment of benefits and specific written request for
disclosure of specific plan documents.
[Page 70253] |
No legal assignment of benefits, no response
required; no specific written request, no disclosure obligated,
however failure to establish and comply with claim procedures,
administrative remedies are considered to be exhausted. Lawsuit may
follow.
[Page 70271] |
|
|
|
|
New protections for pre-service claims and
urgent care claims against improper pre-authorization,
pre-certification and utilization review as well as urgent cares.
[Page 70248 & 70271] |
Understanding of differences in pre-service,
urgent care and post-service claims will save big money in fiduciary
breach liability claims and POSSIBLE
medical malpractice claims. [Page
70248 & 70271] |
|
|
|
|
New definitions of relevant documents and
disclosure obligations, no more medical necessity secrets, UCR fee
schedule confidential
[Page 70252]
[29 CFR § 2560.503-1 (h)(2)(iii) (m) (4), Page 70268, 70271]
[DOL FAQ B-5] |
No legal assignment of benefits, no obligation
to disclose to an assignee, assignment verification by the plan is
allowed and protected.
Update SPD and any guidelines, only use disclosable and
qualified medical claim reviewers.
[Page 70252]
[29 CFR § 2560.503-1 (h)(2)(iii) (m) (4), Page 70268, 70271]
[DOL FAQ B-5] |
|
|
|
|
A Full and Fair Review with new definitions and
protection requires de novo reviews on two appeals by at least four
different people, two different fiduciaries with ERISA plan, and
two different Health-care professionals independent to the ERISA
plan.
[29 CFR § 2560.503-1 (h) (3)(ii)(iii)(iv)(v), Page 70268-9, (m) (8), Page 70271]
[Page 70252-70253] |
Update
SPDs with New Standards and compliance, specify and designate
only qualified fiduciaries for appeals, establish new complaint
appeal procedures, use only disclosable and licensed as well as
certified health-care professionals for medical reviews,
pre-certification and prior authorizations in every case.
[29 CFR § 2560.503-1 (h) (3)(ii)(iii)(iv)(v), Page 70268-9, (m) (8), Page 70271]
[Page 70252-70253] |
|
|
|
|
New clarifications on state law preemptions and
"independent" medical reviews. No preemption for state laws unless
prevention of the application of the new regulation
[Page 70254] |
Comply with both
the regulation and state laws in claims involving mixed
treatment and eligibility determinations and pure medical treatment
decision-makings.
[Page 70254] |
|
|
|
|
New clarifications with new definitions claim
denial/an adverse benefit determination (payment<100% claimed)
or Overpayment, and new protections.
(DOL FAQ C-12) |
Overpayment vs. an adverse benefit
determination, recoupment vs. appeal procedures.
(DOL FAQ C-12) |
|
|
|
|
SPDs must
describe...... |
No SPDs, No
decision making |
|
|
|
|
Insurance company's decision-making power and
disclosure obligations must be described in SPD
[29 CFR 2520.102-3 (q), Page 70242] |
Fully-insured plans with a health insurance
issuer being wholly or partially responsible for administering the
plan (e.g. payment of claims) must describe insurer's role in SPD.
[29 CFR 2520.102-3 (q), Page 70242] |
|
|
|
|
Claim fiduciary, whoever makes denial
appeal decisions, has duties to disclose
SPD and relevant document
[29 CFR § 2560.503-1 (h)(2)(iii), (3)(iii) Page 70268-9, (m) (8), Page 70271] or may face up to $110 a day penalty under "Prudent Actions by Plan
Fiduciaries" and "Enforce Your Rights."
[29 CFR § 2520.102-3, Page 70243] |
Claim fiduciaries or plan fiduciaries
have new duties to disclose, without charge,
SPD and relevant
document
[29 CFR § 2560.503-1 (h)(2)(iii), (3)(iii) Page 70268-9, (m) (8), Page 70271] when claim for
benefits is denied or delayed, or may face up to $110 a day penalty
under "Prudent Actions by Plan Fiduciaries" and "Enforce Your
Rights."
[29 CFR § 2520.102-3, Page 70243] |
|
|
|
|
More.... |
More.... |
|
And
many more new and
important
provisions and protections for health-care providers and
insurance companies/ERISA plans/TPA's, as well as patients and
employers. |
|
|
|
Surprisingly and ironically, under current national health-care crisis for
everyone, most of us, healthcare providers, payers and administrators,
patients and employers, are not ready for this new federal claim regulation,
its meaningful and practical compliance and enforcement may save all of us
from worsening of national health-care crisis.
|
The Most Powerful & only Seminar in the
U.S.
Focused on Health Care
ERISA
Claim Regulation Compliance & Appeals For Everyone!
Details on
Seminar Page
Seminar Schedules in
IL, VA,
NC,
Teleconference
Call 630-736-2974
FAX to (630) 736-1439
Only One
Payment from Your Denied Claims
May Pay off the Seminar or
Book Itself!
Why Not Take Actions to Save 40% of Your Business & Headaches?
|
|
|
|
Due to the
recent demand from the
ERISA plans and TPA's, we're pleased to announce
that we also provide educational and consulting services to the ERISA plans,
TPA's and managed care organizations on
New
Federal Claim/ERISA Regulations and
Compliance, however we do not provide any services involving actual claim
dispute or legal advice for any legal matter or disputes. |
|
|
|
Associations for Physicians, Hospitals, Health-care Providers
We are willing to work with any
associations with your co-sponsorship and significant discount for
tuitions and reference books. You may
e-mail or
telephone for more details. |
|
ERISA OVERHAUL OF U.S. HEALTHCARE
FOR SURVIVAL
"Zhou's Model of Prudent Health Care"
Are All
Consultants Corrupt? (Fast Company)
|
|
U.S. Health-care Crisis
& ERISA Criminal Enforcement
ERISAclaim.com - A $1.0 Trillion Nuclear Solution to U.S. Health-care
Crisis & $44 Trillion Budget Deficits
ERISAclaim.com: 50% Savings - Healthcare Crisis Turnaround for
Employers, Insurers & TPA's
ERISAclaim.com - 950,000 MD's Settled With Aetna & Cigna on ERISA
ERISAclaim.com: ERISA Certification Programs
for Cost-Saving & Reimbursement by Compliance
ERISAclaim.com - U.S. Health-care Crisis
& ERISA Criminal Enforcement
DOL +
DOJ Enforcement of
ERISA
 |
& |
 |
HHS Works with
ERISA (+77 Millions/4 Yrs)
|
Denials +
Recoupment =
Inflation +
fraud or
Cost-Sharing?
Rx =
Compliant Denial & Appeals! |
|
Forbes.com: "Roughly one in seven Americans has
no health insurance. That hurts HCA Inc. (nyse:
HCA -
news
-
people), the largest U.S. hospital chain, which
last year wrote off $2.21 billion
of revenue because patients couldn't pay their
bills."
The American Hospital Association (AHA): "Hospitals today are faced with the challenge of managing their
limited resources, while continuing to deliver the highest standard of care.
According to health care experts, the cost of clinical
denials to individual healthcare organizations averages
$3.3 million
annually. However, many hospitals do not have the resources or the
expertise needed to avoid unpaid days at the end of admissions and lead the
denial-appeals processes."
Payments Go Under a Microscope (washingtonpost.com)
"MAMSI and CareFirst recoup overpayments to doctors by making
deductions from future reimbursements.
Doctors can appeal insurers' decisions.
But, in the end, they usually pay up, doctors and insurers agree."
Hospital Pricing and the Uninsured,
Glenn Melnick, Ph.D.,
"Price
Gouging"
(Subcommittee on Health
Hearing on the Uninsured,
U.S.
FILES COMPLAINT AGAINST NATIONAL ACCOUNTING FIRM UNDER FALSE CLAIMS ACT
(DOJ
Press Release) "January 5, 2004
- PHILADELPHIA –
United States Attorney Patrick L. Meehan announced today the filing of the
Government's
complaint against national accounting firm Ernst & Young.
According to the complaint, nine hospitals paid Ernst & Young for billing
advice – advice which later caused the submission of false claims to the
Medicare program."
USATODAY.com - Hospitals Sock Uninsured with Much Bigger Bills
GM to Report $60B in Future Health-Care Obligations
|
|
|
A
New Diagnosis & Prescription for
Our Nation's Health-care Crisis
Contrary to
the popular belief, our nation's health-care crisis has been truly
and mainly caused by the
lack of understanding and
failing in compliance with
ERISA, the federal law regulating about
80% of
health-care claims or
60% of
health expenditures in the U. S. by both
insurance/benefits
industry and health-care providers for 28 years, through reckless
and
fraudulent as well as
revengeful, inflationary spiral
billings and
claim denials that
destroyed
or foreclosed the hope,
faith and
the Law
&
Order for our nation in health-care quality and
cost control, and the lack of meaningful and practical federal
administrative
enforcement of ERISA claim regulations, because this
inflationary spiral skyrocketing increases in
managed
care claim and denial war behind
ERISA shield between
health
insurers/ERISA plans and healthcare providers
have
overwhelmingly outnumbered increases in cost of living and national
gross domestic products, causing
annual
double-digit increases in
health
insurance premiums and
skyrocket health-care costs
($1.55
trillion
in 2002, 14.9% of the U.S GDP)
after
every managed care strategy and
model
failed to
contain or control health-care costs in long run
despite short-term savings, while entire country has devoted
more and more money in
litigation,
legislation
and
noncompliant managed care campaign, which practically have
solved little or no problem.
In order to
resuscitate U.S. Healthcare/managed care from such a
critical
condition, the strategy and solution must to be a common ground
acceptable to all parties involved, instead of hostile and contradictory
debate of punitive
damage therapy vs.
the uninsured coverage in
Congress. This
common ground for our national health-care crisis is the
ERISA
Claim Regulations, applicable and existing laws and regulations on
the book, originally designed by Congress in 1974 to
regulate
health-care claim dispute and to avoid fiduciary breach and
failures we are facing today.
A new practical and effective solution to
saving our nation's health-care system is to implement
ERISA as
Congress intended by creating a new
occupation or profession, ERISA claim specialists and departments,
t0 bridge the gap FROM
medical billers and coders &
insurance claim processors TO lawyers for both health-care providers and
insurance companies/ERISA plans, and to
educate everyone in health-care and employee benefits system,
health-care providers and their associations and leaders,
IPA's, MCO's,
health insurance, employee benefits TPA's and
legislators as well as
regulators to
truly understand ERISA, and comply with existing
ERISA's claim procedures and benefits
administration rules, to make practical sense for
health insurance delivered as
employee
welfare benefits under ERISA,
protecting participants and beneficiaries and safeguarding plan assets
through compliance of
ERISA laws and regulations by everyone.
How do
we know this is the right diagnosis and prescription?
Plain and simple, imagine what
would happen if the U.S. healthcare superhighway transported
$1.55 trillion for 283 million Americans each year without an
understanding, without compliance by any
one and
without
the enforcement of any existing
laws and
regulations governing those
80% of
the
healthcare claims,
60% of the
healthcare expenditures and
163 million Americans under
ERISA?
The latest Harvard & RAND study for Congress and state legislative debate on Patients'
Bills of Rights, conducted by David Studdert and Carole Roan Gresenz,
study authors from the Harvard School of Public Health and RAND, funded
by federal government, Department Of Labor, and Agency for Health Care
Research and Quality, revealed that
"little is publicly known about such appeals system", and concluded
that "A
majority of preservice appeals disputed choice of
provider or contractual coverage issues, rather than medical necessity.
Medical necessity disputes proliferate not around life-saving treatments
but in areas of societal uncertainty about the legitimate boundaries of
insurance coverage. Greater transparency about the coverage status of
specific services, through more precise
contractual language and consumer education about benefits limitations,
may help to avoid a large proportion of disputes in managed care."
A
JAMA Editorial commenting this study further supported the
conclusion of this study and advanced the
right solutions
more precisely at
New
ERISA Claim Regulations: "Regulations
issued by the Clinton administration in 2000
were designed to infuse rigor into the appeals process maintained by
employer-sponsored health plans covered by the Employee Retirement
Income
Security Act (ERISA),10 which governs insurance arrangements
for more than 150 million workers and their family members. Whether
these rules will be vigorously enforced remains to be seen."
This valuable study has pointed out the direction but failed to provide
a turnkey practical solution.
ERISAclaim.com has provided this nation with a turnkey operational
solution with ERISA compliance, to educate
everyone on ERISA, coverage and
claim
procedures, to ensure "Bill Of Rights" for Patients, Providers, Plan
Sponsors and Insurers.
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Sidebar - Humor
(Copyright © 2004
by
Jin Zhou,
ERISAclaim.com)
Federal Court Managed Care Secret
The Judge:
Counselors, it's tough, too many class
action lawsuits across the Country.
HMO Lawyer:
Your honor, we specialize in managed care
"Bundling & Down Coding" Practice.
The Judge:
Consolidating and bundling all of the
class-action lawsuits across the country and decertifying and
down-coding all of them?
Drs.'s lawyer:
But, your honor, that's racketeering
practice?
The Judge:
Alright, I will allow RICO claims to go
ahead, rest of them, dismissed.
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Codified in Title 29 of the
Code of Federal Regulations:
Regulations
Selected links:
2520.102-3 Contents of summary plan description.
2560.503-1 Claims procedure. |
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ERISA Laws/Rules
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HIPPA Final
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$10,600 ERISA Claim
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| Recent Federal Court Ruling in a Case with
$10,600 medical claim, insurance Co. refused to pay, provider
made numerous demand for payment in almost one year, but no
appeals filed, the court dismissed the lawsuit because provider
failed to exhaust administrative remedy, as required under ERISA,
by filing ERISA claim appeals. This situation is so popular
in health-care community.
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$37,350 ERISA Claim
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| Health-care provider alleged medical claims
submitted to Aetna for reimbursement, Aetna asserted no receipt
of medical claims, no written denials. Health-care
provider failed to present proof of claim submission, claim
denial and ERISA claim appeals. This case was dismissed. ERISA
health-care claims are handled in federal court, state law is
generally not applicable.
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Opinion: Cutting Costs in Half Through Better Management is
Fantasy But Health Care Debate Is Real (The Hartford
Courant)
Excerpt: "If a
talk on economics can have a $650 billion throwaway line,
Treasury Secretary Paul O'Neill delivered it.... "
"O'Neill
insists the problem is not with people, but systems - systems
that invite medical errors, systems that penalize health care
professionals for making honest mistakes, systems that create
the mind-numbing complexity of reimbursement for providers,
systems that reward too much treatment and punish efficiency." |
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ctnow.com
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Health
Cost Trends Shift
"The study said managed care probably has squeezed out all the
savings it can from the nation's health care system and that
employers are turning to other familiar devices such as
increasing premiums and co-payments to trim their costs" |
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