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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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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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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

 

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950,000 MD's Settled
With Aetna & Cigna on ERISA

 

Rx-1  $$$$$$$$$ERISA"Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance
$$$$$$$$$$  Rx-2

US Supreme Court Visits ERISAclaim.com
at 11:57:03 AM on Friday, November 21, 2003

 

 

00-MD-1334-MORENO - In Re Managed Care Litigation


Order granting summary judgment in favor of remaining defendants United and Coventry on all claims* (06/19/2006)
Final Judgment* (09/26/2005)
Order approving settlement among Prudential and physicians, physician groups & organizations, certifying class & directing entry of Final Judgment* (09/26/2005)
Final Judgment* (09/26/2005)
Order approving settlement among Health Net and physicians, physician groups & organizations, certifying class & directing entry of Final Judgment* (09/26/2005)
Final Judgment* (07/20/2004)
Order approving settlement, certifying class & directing entry of Final Judgment* (07/20/2004)
Omnibus Order granting in part and denying in part joint motion to dismiss the second amended consolidated class action complaint* (12/08/2003)

 

 

 

 

 

 

 

 

Humana to settle doctors suit for $58M - 10/19/05 (www.hospitalpricegouging.org)

"OCT. 18 8:51 A.M. ET Health care provider Humana Inc. said Tuesday it agreed to settle a class-action suit filed against the company by physicians alleging the company improperly paid providers' claims by paying lesser amounts than they submitted."

More... | View Settlement

 

AETNA Settlement Agreement (exhibits included)
PART1 | PART2 | PART 3 | PART 4

Breaking News: 07/11/2005


PHYSICIANS AND WELLPOINT, FORMER ANTHEM INC. AND WELLPOINT HEALTH NETWORKS INC. ANNOUNCE SETTLEMENT OF LANDMARK LITIGATION

 

WellPoint Reaches Pact With 700,000 Physicians - 07/11/05 (Wall Street Journal Online)

 

CMA Settles Class-Action Lawsuit With Anthem/Wellpoint - 07/11/05 (California Medical Association Online)

 

WellPoint settles with physicians for nearly $200 million - 07/11/05 (Modern Physician Online)

 

Related Links:
Click to View the Settlement Agreemen (HMOcrisis.com)
Click here to view video of the Press Conference with Archie Lamb on 7-11-05 (bloomberg.com)

 

Related Analysis and links from ERISAclaim.com

Breaking News

950,000 MD's Settled With Aetna & Cigna on ERISA

"Aetna and CIGNA Settlement Secrets"

"Talking Points"

 

 

 

 

 

Aetna, CIGNA CEOs Got 8-Figure Pay Packages (Connecticut Business, March 22, 2005)

"Dr. John W. Rowe, Aetna's chairman and CEO, took in $22.2 million in 2004, including $18.2 million of value from exercising stock options. He also got 250,000 new stock options with a potential value of $6.1 million."

 

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.

 

Tort Reform, Fraud & Healthcare Crisis?

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

ERISAclaim.com - A $1.0 Trillion Nuclear Solution to U.S. Health-care Crisis & $44 Trillion Budget Deficits

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)

 

  1. ERISA stands for Employee Retirement Income Security Act

  2. E. B. = External Boards (of Reviews) (§7.10-7.11): 1) Medical Necessity, 2) Billing & Coding and 3) Policy Coverage

  3. Settlements Only for MCO/Provider Contract Disputes

  4. Settlements Not for Patient Coverage/ERISA Disputes, (§7.10-7.11)

  5. Patient Disputes = ERISA/Coverage/Medical Necessity/Bundling & Down Coding

  6. Provider Disputes = PPO Discount/HMO Capitation/Provider Relationship (DOL FAQ A8)

  7. 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)

  8. External Reviews (3 E. B.) Are Not Available until Internal Reviews (ERISA) Completed, (GAO)

  9. ERISA = Federal Law Mandate; External  Reviews = State Law Mandate, (GAO)

  10. No ERISA Compliance = No Rights for Any One

 

 

DOJ: Criminal Resource Manual 2432 Coercive or Fraudulent Interference with ERISA Rights -- 29 U.S.C. 1141

2432 Coercive or Fraudulent Interference with ERISA Rights -- 29 U.S.C. 1141

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

ERISA 510 29 USC 1140 Interference with protected rights.
ERISA 511 29 USC 1141 Coercive interference.

 

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)

 

 

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."

 

 

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." 

It's always ERISA, No Matter Where, How & Who


North Carolina Medical Society  -  HMO Lawsuit Center

"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."
 

Review a Summary of the Complaint
View the Full Complaint - PDF File

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."

 

 

ERISA Failure Syndrome

U.S. Healthcare Crisis Trilogy

(Copyright © 2004 by Jin Zhou,  ERISAclaim.com)

 

ERISA
Medical Killing
ERISA
Medical Inflation
ERISA
Insurance Robbery
"Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance

Read Making a Killing

?

 

?

Bar graph showing trends in hospital charges and revenues in California from 1995-2002

 

 

 

 

 

 

 

?

 

?

GAO-04-312

?
 

?

American Job ExportING!

Mass layoffs up in January 2004

Weirton Steel cancels 10,000

GM: $67.5 billion in 2003

One Nation under Debt: U..S. economy threatened by aging of America

 

Healthcare Disaster at Fault Verdict Index:

U.S. Government 30%

U.S. Employers & Insurers 30%

Healthcare Providers 30%

Consumers 10%

(ERISA Failure + Managed-Care) Destroyed US Healthcare
(ERISA Failure + Managed-Care + HSA) Invite US Federal Budget Deficit & Social Security Disasters = 100X 9/11 Attacks

 

GAO: Current and Emerging Fiscal and Retirement Security Challenges, American Benefits Council/MetLife Conference, Washington, DC, on January 14, 2005

  1. Rising Health care Costs Have Many Implications (Direct)

  2. Rising Healthcare Costs Have Many Implications (Indirect)

 

Rx-1  $$$$$$$$$ERISA"Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance
$$$$$$$$$$  Rx-2

 

The Root of U. S. Healthcare Crisis

Jin Zhou, ERISAclaim.com

The Hearing at Senate Committee on Finance on 3-3-04, [View Video "Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance
or Transcript (PDF) (KaiserNetwork.org)]  revealed the mechanism, nature and extent of ERISA failure and nonenforcement as the reasons for "Growth in Bogus Health Insurance Plans Targeting Desperate Small Business Owners", as being concluded as "No the results are not good. It’s a tragedy." by Ann Combs, assistant secretary of DOL. The mechanism, nature and extent of ERISA failure and nonenforcement as presented at the Hearing are universally true and applicable to all health care claim denials and delays in managed care environment from all employer sponsored health plans as the root of U. S. healthcare crisis.

 

This is a 911 call on "healthcare 9/11 disaster"!

THE 9/11 COMMISSION REPORT (pdf)

 

"Class Actions" v. "New Strike Force"

 

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

Medicare | Fraud, Abuse in Medicare and Medicaid Could Exceed Government Tracking Figures - Kaisernetwork.org

 

"In a statement, Sen. Larry Craig (R-Idaho), Chair of the Senate Special Committee on Aging, said, "In these tight budgetary times, it is important that every dollar that the federal government spends be well spent for its intended purpose ... But as we go after waste, fraud and abuse within Medicare, we need to make sure that we do not overreact."

Health care now prime target of federal False Claims Act (AM News)

"No place for fraud"

"There is no place for fraud in the practice of medicine," said AMA President-elect John C. Nelson, MD. "However, it is important that as the government investigates health care fraud, there is recognition, and separation, of inadvertent errors by health care professionals from real fraud."

 

U.S. Health-care Crisis & ERISA Criminal Enforcement

 

 

Fraud Health Care Cards
"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

 

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

  1. Unusual provider billing practices.

  2. Discrepancy between the submitted diagnosis and the treatment.

  3. Diagnoses or treatments that are outside the practitioner’s scope of practice.

  4. Claims that are resubmitted with coding changes to gain benefits.

  5. Alterations on claim submissions.

  6. 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."

U.S. Department of Justice Seal

Health Care Fraud Report

Fiscal Year 1998

Link to Site Map

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"

 

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"

New Federal Claim Regulation (Final Rule)

  1. "Plans must consult with appropriate health care professionals in deciding appealed claims involving medical judgment." [70268-70269, CFR § 2560.503-1(h)(3)(iii)]

  2. "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).

 

 

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)

 

 

 


 

New York State Seal

New York State, Insurance Department

ISSUED 4/13/2004

FOR IMMEDIATE RELEASE

Health Net To Refund $4.99 Million To Policyholders And Re-Evaluate Some Healthcare Claims  (The full report, pdf)
Also Paid $500,000 Fine And Instituted Remedial Actions Under Separate Department Action

 

 

Press Releases

Department of Law
120 Broadway
New York, NY 10271
 
Department of Law
The State Capitol
Albany, NY 12224
 
 
For More Information:
(212) 416-8060
For Immediate Release 
March 30, 2004
New Report Shows HMOs Do Not Adequately Comply with State Law
 

ATTENTION RADIO NEWSROOMS:
AN AUDIO CUT IS AVAILABLE BY CONTACTING THE ATTORNEY GENERAL'S 24 HOUR TOLL-FREE NEWS LINE AT (877) 345-3466, CHOICE #1.

 
Press Release

Survey Report - (HTML Version | PDF Version)

 

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)

 

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, Tuesday, March 09, 2004)

 

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."

 

The latest and updated RAND/Harvard Study, funded by the U.S. Department of Labor (DOL) and requested by Congress, examines the outcomes of nearly a half-million coverage requests in two large medical groups and revealed the following:

 

 

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.
 
Don't wait for another 28 years, it's not too late to take actions to become in compliance for your own benefits and protections.
 
 
Our seminars are for everyone, physicians, health-care providers, clinics, hospitals, insurance companies, ERISA plans, third party claim administrators and plan sponsors as well as state insurance regulators.

 

Only with understanding of the regulation and other partners and alliances in our nation's health-care system, our national health-care system will survive and prosper.

 

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.

 

A New Diagnosis & Solution:
EFS-- ERISA FAILURE SYNDROME--Fatality: 31 YOA
 

ERISA Failure, Noncompliance and Nonenforcement of ERISA SPD and Claims Procedure Rules, Is the Damaged or Missing Foam on U.S. Healthcare Wings!

HMO Crisis Is Really An ERISA Crisis!

HMO & PPO Managed Care Contracting to 
Disregard & Substitute
ERISA SPD & Claims Procedure
Is The Primary & Inevitable Cause of Medical Inflation

Costly Managed Care & Medical Malpractice Lawsuits
American Job Export!

 

ERISA Failure Damages Are Greater Than
9/11 and Pearl Harbor Tragedies Combined

U.S. Health-care Crisis & ERISA Criminal Enforcement

 

Only practical solution is to cut the skyrocketing healthcare care costs and increase the healthcare coverage and benefits at the same time without having to go to Congress to reinvent another new "Mars Project" or "Universal Uninsured Bill of Right"- "John Q. ERISA Enforcement".

ERISA OVERHAUL OF U.S. HEALTHCARE FOR SURVIVAL

 

"Zhou's Model of Prudent Health Care"

Are All Consultants Corrupt? (Fast Company)

    The First Overhaul for U.S. Health care and GM Is to ERISA-Overhaul GM Health Care Model with Followings:

  1. ERISA Compliant SPD with Complete Benefits Coverage, Limits & Exclusions;

  2. ERISA Compliant Claims Procedure as the Only Rule for Every One;

  3. Elimination of Any Third-Party Managed Care Contracts, UCR & "Medical Necessity"

(GM Current Model: $5.1 billion/yr, $1,400/vehicle)
(GM to Report $60B in Future Health-Care Obligations)

Rx-1  $$$$$$$$$ERISA"Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance
$$$$$$$$$$  Rx-2

General Motors National Benefit Center

Health Spending Projections Through 2013

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)

U.S. Health-care Crisis & ERISA Criminal Enforcement

CBO's analysis of the President's budgetary proposals for fiscal year 2005

Fact Sheet: Affordable Health Care for America's Families (White House)

 

 

DOL-Reporting and Disclosure Guide for Employee Benefit Plans (pdf)
Compliance Assistance for Group Health Plans (Top 15 Tips)

950,000 MD's Settled With Aetna & Cigna on ERISA
"Aetna and CIGNA Settlement Secrets"
ERISA Certification Programs for Maximal Reimbursement

What You Should Know about Filing Your Health Benefits Claim
HIPAA Nondiscrimination Requirements Frequently Asked Questions

 


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, Tuesday, March 09, 2004)

 

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.

 

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.

 

DOL Compliance Assistance for Health Plans

 

 

 

Statutes (United States Code) 
ERISA - Title 29, Chapter 18. 

        Selected links:

Sec. 1002.
Definitions

Sec. 1003.
Coverage

Sec. 1022.
Summary plan description
Sec. 1104.
Fiduciary duties

Sec. 1140.
Interference with protected rights

Sec. 1141.
Coercive interference

part 7
group health plan requirements

 

 

Code of Federal Regulations

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.

 

 

 

ERISA Laws/Rules

 

 

Report of the ERISA Advisory Council's Working Group on Fiduciary Education and Training (U.S. Department of Labor, Employee Benefits Security Administration)

Excerpt: "We strongly urge anyone interested in the issue of fiduciary education to read through the transcripts of our work group's hearings ..."

 

HIPPA Final

 

AMNews through  AMA

Health plans subject to new federal appeals rules
Much-postponed regulations offer patients and doctors fairer and faster review, plus new rights, Dept. of Labor says.

 

ERISA Not Insurance

Aetna Video Shows ERISA Patients Mistreated

 

"According to the video, when faced with claims for identical medical problems, Aetna separates the claims where no damages are available - those subject to the federal Employee Retirement Income Security Act, or ERISA - from non-ERISA claims, where consumers can sue.1 2"

 

Aetna Reaches Agreement with Physicians, May 22, 2003 (Aetna.com)

 

 

Managed Care and Patients' Rights
(JAMA Editorial)

 

$10,600 ERISA Claim

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.

 

 

$37,350 ERISA Claim

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.

 

 

 

PACIFIC COAST HOSPITAL v. AETNA HEALTHCARE

"requesting payment of benefits and/or to discuss the matter in further detail" by hospitals are wasting time and money

 

 

One Employee, One Shareholder, But ERISA Plan

(Name of the Game for 80 Percent of Health-care Claims in U.S.)

Gilbert v. Alta Health & Life Insurance Co. (11th Cir. No. 01-10829,12/27/01).

 

NHPF Publications  

 

NHPF Publications  

 

NHPF Publications  

 

 

2002 Employee Health Benefits Survey (Kaiser Family Foundation)

 

Survey: Employee Benefits in Private Industry (2000) (U.S. Department of Labor, Bureau of Labor Statistics)

 

Government Survey: Employee Benefits in Private Industry, 2003 (U.S. Department of Labor, Bureau of Labor Statistics)

 

Are more workers covered by traditional fee-for-service plans, HMOs, or PPOs?

 

Definitions of Health Insurance Plans and Other Terms (Federal Government’s Interdepartmental Committee)

 

 

 

 

DOL Secretary Testifies to Committee About ERISA Enforcement, Compliance Assistance (U.S. Department of Labor, Pension and Welfare Benefits Administration)

 

 

Study: Health Insurance Premiums Rose More Than 30 Percent Between 1996 and 2000 (U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality)

 

 

 

 

 

 

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."

 

ctnow.com

 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"

 

 

Independent Medical Review Experiences in California (California HealthCare Foundation)

 

 

Health Care Issues Stymie Congress (The Hartford Courant)

 

 

 

 

 

 

Kinder and Gentler: Physicians and Managed Care, 1997-2001 (Center for Studying Health System Change)

 

 

 

 

 

 

Employer Spending on Health Care: 1987-2000 (Employee Benefit Research Institute)

 

Office for Civil Rights - HIPAA

OCR Guidance Explaining Significant Aspects of the Privacy Rule- December 4, 2002

 

 

Health Care Spending Rose 8.7% in 2001, the Fastest Rate in 10 Years, Government Statistics Say

 

In Largest Increase in 12 Years, Health Care Spending Rose 7% in 2000 ...

 (KaiserNetwork.org)

 

 

Employer Health Benefits: 2002 Annual Survey.(pdf)
Accessibility verified January 30, 2003
(KaiserNetwork.org)

 

 

National Compensation Survey: Employee Benefits in Private Industry in the United States, 2000 (PDF) (U.S. Department of Labor, Bureau of Labor Statistics)

 

Government Survey: Employee Benefits in Private Industry, 2003 (U.S. Department of Labor, Bureau of Labor Statistics)

 

 

Data Provide Details on Characteristics of Health Insurance of U.S. Workers (Agency for Healthcare Research and Quality)

 

 

GAO Report: Improvements to Retirement Income Data Needed (U.S. General Accounting Office)

"What GAO Recommends:

The Congress should consider directing Labor to obtain from plan administrators electronic filings of SPDs and summaries of material

modifications and make them publicly available."

 

 

 

 

 

   
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