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A CONSUMER GUIDE TO HANDLING DISPUTES WITH YOUR PRIVATE OR EMPLOYER HEALTH PLAN -

 

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2003_02 | Deal With Patient Complaints Before Arrival of Subpoenas

(managedcaremag.com)

HMOs should adopt a conflict-management, rather than dispute-resolution, approach to patient complaints.

 

 

Blue Cross Blue Shield Plan Administrative Expenses Approximate 11% of Premiums, According to Sherlock Company

 

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58-17C-47      Prohibition against compensation influencing or based upon review decisions.

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58-17C-67      Activities of nonregistered utilization review organizations prohibited.
 

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Minnesota UR Statutes 2004 Table of chapters

CHAPTER 62M

UTILIZATION REVIEW OF HEALTH CARE

 

MN UR Act Summary for Chapter137

 

ND: 26.1-26.4

Health Care Service Utilization Review

SB 2184 – Minimum standards for utilization review (26.1-26.4-04). Provides for utilization

review standards consistent with federal law and with standards established by the United States

Department of Labor.

 

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ERISA Webinar Handout | 03-15-2010

Create an ERISA Appeals Department

for Your Hospital or Practice

Please e-mail for further notice & details

630-736-2974 (Office), 630-808-7237 (Mobile)

 

New Federal Health Claims & Appeals Laws & Regulations

for 193 Million Americans

Effective 09-23-2010

©2010, Jin Zhou, ERISAclaim.com

Photo of President Gerald R. Ford signing Employee Retirement Income Security Act of 1974

President Obama Signing Health Bill on 03/23/2010

President Gerald R. Ford Signing ERISA on 09/02/1974

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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ERISA Claims Regulation - 29 CFR 2560.503-1: Regulation FAQ Fact Sheet Claims Guide Claims Card

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bullet Health Claims Related Information
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Webinars, Seminars & Certification Classes for New Federal Health Claim Appeals Regulations

 

ERISAclaim.com - Free Webinar - Reimbursement Laws for Healthcare Providers & Health Plans

 

ERISAclaim.com: Seminars - 2010 Two-day Basic ERISA Appeal Seminars - Denials and Overpayment Appeals

 

ERISAclaim.com - 2010 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)

 

Helping make sense of health care reform (San Francisco Chronicle, August 10, 2010)

"Q: Are most plans going to stay grandfathered?

 

(Borzi ) A: I had the strong sense that most companies, at least initially, would want to stay grandfathered to see what the whole panoply of regulations would look like, and then decide. What I hear is that a lot of the large companies don't want to do the analysis to decide (whether it makes sense to stay grandfathered). They are just going to assume they are not grandfathered."

 

"Borzi is head of the U.S. Department of Labor's Employee Benefits Security Administration,"

Survey Notes Most Health Plans to Lose Grandfathered Status | workforce.com - August 11, 2010  

"Seventy-two percent of employers expect their health care plans to lose their grandfathered status because of design changes. Changing premium subsidy levels, changing insurers and consolidating plans are among other actions employers expect to result in their plans losing grandfathered status."

 

ERISAclaim.com Press Release

The New TPA ERISA Appeals Department Training Program Announced for Self-Insured Health Plan’s Denial and Appeal Management To Compliantly Contain Administrative Costs 02-11-2010, Hanover Park, IL


The New Hospital ERISA Appeals Department Program Announced for Hospital In-House Denial Management and Financial Crisis Turnaround  02-08-2010, Hanover Park, IL

"For The First Time In U.S. Health Care History, ERISAclaim.com Announced The Nation’s First Hospital ERISA Appeal Department Program To Provide Hospital With A Turn-Key Set-Up Training For The In-House ERISA Appeals Department To Combat Commercial Managed Care Denials, Overpayment Recoupment Crisis, And Revenue Cycle Outsourcing Dilemmas For Hospital Survival, And ERISA Compliance, In Wake Of The Latest AHA Report Of More Than $36 Billion Hospital Uncompensated Care Cost"

 

"ERISAclaim.com’s Hospital ERISA Appeals Department program starts at $50,000 (+actual expenses for travel and hotel for speaker) for up to 5 ERISA Claim Specialists Certification training and 30-day live phone and Webinar supports. Each additional ERISA Claim Specialist costs additional $8,500. An additional six-month support starts at $50,000 and one-year support at $100,000 for ERISA Appeals Department with trained ERISA Claim Specialists.

 

ERISAclaim.com also provides ERISA Claim Specialist Certification Training Classes for non-institutional providers in major U.S. cities."

 

Hospital ERISA Appeals Deaprtment = On-site ERISA Claim Specialists Certification Training + Live Phone & Webinar Support at a Price of One of the Recovered Hospital Claims!

For a complete copy of this Press Release, click here

ERISA for Hospitals Reimbursement Turnaround

by Jin Zhou, 07/29/2005

© 2005, Jin Zhou, ERISAclaim.com

 

The New TPA ERISA Appeals Department Training Program Announced for Self-Insured Health Plan’s Denial and Appeal Management To Compliantly Contain Administrative Costs 02-11-2010, Hanover Park, IL

For The First Time In U.S. Health Care History, ERISAclaim.com Announced The Nation’s First TPA ERISA Appeal Management Department Program To Provide TPA’s and Self-Insured Health Plans With A Turn-Key Set-Up Training For The In-House ERISA Appeals Management Department To Process ERISA Appeals Compliantly to Contain Administrative Costs and Avoid Unnecessary Litigations, In Wake Of The New Pending Obama Health Reform Laws Mandating ERISA Compliance for All Group Health Plans Within Six Months of The Enactment

ERISAclaim.com: 50% Savings - Healthcare Crisis Turnaround for Employers, Insurers & TPA's

 

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

 

American Benefits Council: News Room - Supreme Court Ruling on Health Care Claims Raises Important Policy Issues: American Benefits Council. June 21, 2004

"Sadly and predictably trial attorneys and their allies are already calling on Congress to unravel today’s decision by the Supreme Court, but they should first ask why the two physicians in these cases did not act swiftly to help make sure their patients got the care they were seeking. In neither case did the patient or their physician seek a further review of the health plan’s initial coverage decision, despite being specifically informed of their right to such a review under federal law." Klein said."

 

"These review procedures are available under ERISA to help patients get the care they deserve, quickly and without having to resort to costly and lengthy legal procedures. Clearly, a speedy and factual review aided by the expertise of the physicians involved with these two cases could have avoided the need for the courts to be involved at all," Klein said."

 

# # #

The American Benefits Council is the national trade association for companies concerned about federal legislation and regulations affecting all aspects of the employee benefits system. The Council's members represent the entire spectrum of the private employee benefits community and either sponsor directly or administer retirement and health plans covering more than 100 million Americans."

http://www.americanbenefitscouncil.org/issues/health/mischealth.htm

 

 

Certification Programs

Modules

Seminar Topics

I

2 Days
14 hours
$2,650 (Includeing 2010 CD-Book & Appeal System - $450)

The New Healthcare Reform Is Final on Provider Reimbursement Laws - ERISA Appeals Procedures Mandatory for All Group Health Plans and Healthcare Providers

 

HR3962: Affordable Health Care for America Act

HR3590: Patient Protection and Affordable Care Act

Supreme Court Managed Care ERISA Watch
ERISA Demystified, ERISA Basics, Principles and Health-care Claims, Managed Care Problems, Healthcare Crisis;
Definitions of Health Insurance Plans and Other Terms;
What You Should Know about Filing Your Health Benefits Claim;
Patient's Rights Claims Procedure Regulation (Fact Sheet)
HIPAA Nondiscrimination Requirements.
HSA &/Or  ERISA? 95% of HSA Are Still ERISA's!

ERISA Appeal v. New CMS Appeal Rules, Knowing both = The Best


II

2 Days
14 hours
$2,450

 

New Federal Claim Regulation (Final Rule);
Amendments to Summary Plan Description Regulations (Final Rule)
;
Benefit Claims Procedure Regulation (FAQ);
Guide to Notices Required by HIPAA and Other Provisions in Part 7 of ERISA's Title I;
Answers: Recent Changes in Health Care Law;
ERISA in HMO, POS, PPO & MCO, Pre-certification under ERISA Plans;
Aetna & CIGNA Settlement Demystified.

Aetna ERISA "Talking Points"

III

2 Days
14 hours
$2,450

 

DOL-Reporting and Disclosure Guide for Employee Benefit Plans;
State Insurance Department & Coordinate with ERISA;
Continuation of Health Coverage – COBRA;
How to Read Real SPD's, PPO Manual;
How BlueCard PPO Works under ERISA;
State Law Preemption, Benefits Denials &  Appeals;
ERISA Application in Healthcare denials, Hands-on common EOB/denial  ERISA;
Dissection & Appeal Strategy.
Medicare & ERISA, Medicare Secondary Payer (CMS) and Debts "Overpayment" Recovery.

IV

2 Days
14 hours
$2,650

 

Prompt Pay Laws;
External Review Laws;
Utilization Review;
Medical Necessity Appeals & Strategy;
Pre-existing Condition Appeals & Strategy;
UCR, Bundling & Downcoding Appeals & Strategy;
Overpayment Refund & Recoupment Disputes Appeals & Strategy;
U.S. Health-care Crisis & ERISA Criminal Enforcement;
HHS-OIG-Corporate Integrity Agreements
High-tech Appeal Automation
And
More, Appeal Strategy.

Disclaimer

Copyright  Notice


Except for otherwise specifically stated, our educational and training for certification programs are not affiliated with any governmental or educational institute for the purpose of  "recognized accreditation or certification for compliance programs or compliance officers" or degrees. Our certifications are only for personal attendance in private studying subject materials specified in each individual programs for advancing educational knowledge with respect to applicable business and  compliance.

 

OIG: Special Advisory Bulletin: Practices of Business Consultants [PDF] [http://oig.hhs.gov/fraud/docs/alertsandbulletins/consultants.pdf]
The Office of Inspector General (OIG), Department of Health and Human Services
, June, 2001

 

Tape or any forms of digital recording are not allowed. Copyright © 2001-2009

 

 

Seminar Goals:

 

  1. To Understand Basic Definitions Of ERISA Claim And SPD Regulation And Appeal Practice;
  2. Sufficient Understanding of Relevant Provisions Of ERISA Claim Regulation, CFR ERISA §2560.503-1;
  3. Sufficient And Advanced Understanding of  DOL Guidelines Of ERISA Claim Regulation And Appeal, DOL ERISA FAQ;
  4. Sufficient And Advanced Understanding of  Relevant Provisions Of ERISA Summary Plan Description (SPD) Regulation, ERISA Version of Insurance Policy under Federal Law-SPD;
  5. Advanced, Practical and Strategic Application Of The ERISA Claim And SPD Regulations In Healthcare Claim Appeals;
  6. Sufficient And Advanced Understanding of Most Significant U.S. Supreme Court And Federal Court Rulings, Case Laws, For ERISA Claim Litigation And Appeals;
  7. To Understand How To Quickly Identify ERISA Plans;
  8. To Understand How To Identify Plan Administrator From the ERISA Plans;
  9. Sufficient And Advanced Understanding of How To Read Insurance Denial Notification/EOB From ERISA Standpoint;
  10. Sufficient And Advanced Understanding of  Relevant State Laws And Managed Care Regulations In Support Of ERISA Appeals;
  11. Sufficient And Advanced Understanding of General Principle And Practical Applications Of Denial Fact Findings, Laws And Regulations And Appeal Strategies;
  12. Sufficient And Advanced Understanding And Practice in How To Appeal Commonly Seen Denials Under ERISA In Healthcare Claims, Policy Exclusion And Limitation, Medical Necessity, UCR, Precertification/Prior Authorization, Pre-Existing Condition Exclusion, Subrogation, Coordination Of Benefits/EOB, Lack Of Documentation, Lack Of Authorization To Appeal, And More……;
  13. Sufficient Understanding And Advanced Practice In  How To Appeal Claim Denials And Delays With Very Specific Allegations of ERISA Violations From Payers, Beyond and Above Coding, Billing and PPO/HMO Contracting Arguments;
  14. Sufficient Understanding And Advanced Practice In How To Appeal Overpayment Recoupment Demand And Withholding/Embezzlement;
  15. Sufficient Understanding And Advanced Practice In The Legal Principles And Procedures In Fraud And Abuse Prevention For Healthcare Provider And Benefits Administrators, Especially Distinguished Application In Pure Benefits And Coverage Denials v. Pure Fraud and Abuse,  And Mixed Fraud and Abuse with Benefits  Coverage Denials
  16. Sufficient Understanding And Advanced Practice of Federal Law And Regulations On Indigency Policy, Discount Programs In Compliance With Federal Laws, A New Risk That Unkown to Providers In Overpayment And Fraud Disputes;
  17. Sufficient Understanding And Advanced Practice In How To Communicate With Attorneys Retained By ERISA Plans And Plan Administrators Of Self-Insured Health Plans For Speedy Settlement;
  18. Sufficient Understanding And Advanced Practice In How To Quickly Identify And Correctly Use The Sample Letters From ERISA Appeal CD Book From Jin Zhou Of ERISAclaim.com;
  19. Based On The Individual Practice, To Identify and  Make Recommendations And Changes For Medical Practice Forms, Such As Legal Assignment Of Benefits, Medical Necessity, Financial Discount/Corporate Indigency Policy;
  20. How to Write Effective Appeal Letters for Healthcare Providers Specifically in Accordance with ERISA Claim Regulation..
  21. How to write Benefits Review (Appeal Response) Letters Specifically in Compliance with ERISA Claim Regulation.
  22. Sufficient Hands-On Simulated Case Practice and Trainings.
  23. Will Answer Any Specific Questions From The Real Claim Denials On Ongoing Basis During The Seminar.

 

Maximal Healthcare Claim Reimbursement
through ERISA Compliance

 

ERISAclaim.com provides unique and unprecedented certification programs for health-care ERISA claims denials and appeals through ERISA compliance in assisting  healthcare providers, physicians, clinics and hospitals in their business survival from reimbursement crisis.

 

Federal Law, ERISA, regulates and governs approximately 80% of U.S. health-care claims and 60% of national health-care expenditures, while in past two decades medical coders, billers and reimbursement managers or staffs are historically and practically clueless about this ERISA statutory and regulatory superpower for their business survival and development, and no ERISA educations or trainings have been received by entire reimbursement industry, because there isn't anyone available, not even one book or resource out there practically and meaningfully  available on this most important legal subject in health-care reimbursement business and industry.

 

Licensing of ERISA-Covered Benefit Plan Administrator, New York State Insurance Department, January 26, 2000

 

Letter opinion per CIC §12921.9 : Discretionary Clauses, (PDF) John Garamendi, Insurance Commissioner, DEPARTMENT OF INSURANCE, STATE OF CALIFORNIA, February 26, 2004

More than 70% of healthcare claims denied or delayed each year were not because of coding or billing errors or disputes, but due to non-coding and non-billing related reasons, such as policy exclusion, medical necessity/utilization reviews, pre-existing exclusions, pre-certification, prior-authorization, PPO bundling and downcoding and "unknown" or unexplained reasons. Yet all denials and delays were handled by coding and billing staffs, while up to 80% of healthcare claims are ERISA claims and these coding and billing staffs have no training and knowledge in ERISA, coverage dispute, appeal procedures. No one seems to know what to do, but do whatever they felt need to be done - going circles and frustrations every day.

Coding and billing are less than half of the successful reimbursement practice, coding and billing are not appealing and coverage dispute practice. Many coders and billers are wonderful, non-confrontational and very sophisticated individuals, but they might be terrible and counterproductive debaters, and less than ideal legal reasoning and logical thinkers. Many financial executives are hands-free managers in reimbursement divisions.

 

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 updated Harvard & RAND study, funded by the U.S. Department of Labor (DOL), published on June 18, 2003 through Health Affairs, examined the outcomes of nearly a half-million coverage requests in two large medical groups that contract with health plans to deliver care and conduct utilization review, and discovered the urgency and necessity of expertise of ERISA claim procedure specialists. The study concludes the following in its summary and policy implications:  "....We found much higher denial rates than those previously reported.....Denials made on contractual grounds—the largest share of denials—may call for both clinical and contractual expertise. Hence, they should ideally be made by personnel who are versant in both areas. There was some evidence of this sort of dual expertise being brought to bear on coverage decisions at the two groups we studied."

 

 

"......In this environment, contractual coverage and medical-necessity issues that persist are likely to be for services that enrollees feel especially strongly about. Such consumer concerns, together with ongoing consumer protection agendas that include reforms such as guaranteed external review and right-to-sue provisions, mean that the policy importance of UR denials in managed care is unlikely to wane in the foreseeable future."

 

However these best experts "hired" by Congress and federal government are one step away from the complete discovery and solution. Let us fill in the missing links and connect dots in order to save our health-care system from collapsing and crisis.

 

First, we identify the controlling force and power in contractual policy coverage denial. The majority of Americans are covered under the employer-sponsored health-care programs in private sectors under ERISA, 80% of the claims and 60% of health expenditures are regulated under ERISA. Each individual ERISA plan offers different coverage and benefits, either self-insured or fully-insured through purchase of insurance from an insurance company. The controlling and governing document for each ERISA plan is Summary Plan Description (SPD), the rule of the game for interpreting each SPD and resolving the disputes on contractual denials is ERISA claims procedure regulations. Therefore the experts from Harvard & Rand study group discovered the importance and necessity of "contractual expertise" but aborted the solution of "contractual expertise" due to "the reasons of size or financial stress, this may be beyond the reach of smaller medical groups that have assumed responsibility for UR".

 

Financial burden and unavailability of this contractual expertise could be the final resolution to their study group to determine if those contractual denials were made by the plan or TPA correctly.

Clinical knowledge and expertise from those medical groups are inherited, but "contractual expertise" is missing badly for policy coverage,
Summary Plan Description (SPD) and ERISA Claims Procedure for 80% of health care claims, because such ERISA contractual expertise is nowhere to be found, even for those very experienced health care attorneys and insurance coverage experts, as state law governed insurance policy dispute resolution and ERISA governed claims procedure dispute resolution are quite different, and entire country has never put ERISA into health-care practice. This is why our health-care system failed.

 

Another new Rand/Harvard study published on February 2004 issue of Annals of Emergency Medicine, "Disputes over coverage of emergency department services: A study of two health maintenance organizations" discovered that 90% of denial in utilization reviews were overturned on appeals, from a stratified random sample of approximately 3,500 appeals of coverage denials lodged by privately insured enrollees between 1998 and 2000 at 2 of the nation's largest HMOs. This study concludes: "The prevalence of ED cases among all appeals reflects disagreement between lay and expert judgments about what constitutes emergency care under the prudent layperson standard. The high rate at which enrollees win these appeals highlights significant disagreement in interpretation of the standard among different adjudicators within managed care organizations (medical groups and health plans). When enrollees fail to challenge denials that would be reversed on appeal, they bear the financial brunt of ambiguities in interpretation of the prudent layperson standard."

 

This new Rand/Harvard study warns that "Although the end result for consumers is the same in each of these cases, the messages sent by plans to consumers and medical groups are not. Goodwill payments imply inappropriate use of the ED (notwithstanding the fact that actual merit might not have been assessed). Merit-based overturns, on the other hand, signal an error in utilization review and instruct medical groups about the proper limits of coverage, instructions that medical groups cannot ignore because they must meet the cost of these claims. Hence, merit-based overturns perform a valuable signaling function, akin to the role of judicial precedent in the law. Unless plans invest additional effort in educating utilization reviewers about erroneous decisions for which they are not held financially accountable, goodwill payments of potentially meritorious cases limit opportunities to forge consensus about the limits of the prudent layperson standard and to disseminate accumulated knowledge about its meaning."

 

"Prudent Layperson" Laws Do Not Increase Inappropriate ED Visits (Reuters via Medscape; one-time registration required)

"However, some compliance problems did emerge. Some insurers, Hall told Reuters Health, initially deny ED claims and then "quickly reverse" their decision if challenged.

 

"There are two take-home messages for health professionals," Hall said. "One, insurers much less often question the appropriateness of emergency services and two, if insurers initially deny coverage for emergency care, providers or patients should appeal."

The impact and enforcement of prudent layperson laws (Mark A. Hall, JD, Annals of Emergency Medicine Online, May 2004 • Volume 43 • Number 5)

[ABSTRACT]  [FULL TEXT] [ PDF]

Importantly, ERISA claim regulation and definition of "claim involving urgent care", 29CFR2560.503-1 (m)(1) - Claims Procedure, has provided governing solutions to "disagreement between lay and expert judgments about what constitutes emergency care under the prudent layperson standard." for these privately insured enrollees. And "Unless plans invest additional effort in educating utilization reviewers about erroneous decisions for which they are not held financially accountable," and ERISA claim regulation and  definition of "claim involving urgent care'', goodwill solution will result in backslash for more disasters in Emergency Department across the country.

 

If 80% of the health-care claim and 60% of health expenditures are governed and regulated by ERISA, ERISA plan's "insurance policy" is controlled by each plan's Summary Plan Description (SPD), and each claim dispute is resolved under ERISA claims procedure regulations, such "contractual expertise", called for by our Rand/Harvard experts, must be from ERISA claim procedure specialists.


Therefore, it is absolutely clear that our nation must provide a solution to health-care crisis by urgently establishing an industry or profession that will possess not only clinical expertise but also, and more importantly,
ERISA contractual expertise, ERISA claim procedure expertise.

 

These valuable studies have pointed out the direction but failed to provide a turnkey practical solution.

 

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.

All other 8 major insurance companies named in class-action lawsuits 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.

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.

 

A striking parallel phenomena is also true in the insurance and benefits industry, as described above for medical coding and billing personnel. With the industry compliance tips for the insurance/benefits industry, offered through AAHP in complying with new federal claim regulation, reflected the same problems but provided no practical solutions, the industry is strategically revising the rules of claim processors: "We're taking the claims processors out of the loop. They're good at what they do, but they definitely aren't lawyers. We don't necessarily want them to be making discretionary decisions", said James L. Touse, vice president and associate general counsel for BlueCross BlueShield of Tennessee, at a 2002 policy conference sponsored by the American Association of Health Plans.

 

That is why, starting January 1, 2003, Aetna and any other insurance companies/ERISA plans have come up with a brand-new programs Appeals Administration Services program, parallel to our certification program, in response to this new ERISA Storm, Real Protections for Health-care Providers and Patients, while health-care providers nationwide are still in sleeping mode pursuing moon project of protections through recycling, reinventing and salvaging the ERISA storm and protection as a result of 28 year ERISA health-care crisis and refinery process.

 

From medical coders and billers & insurance claim processors to lawyers for physicians and insurance companies, the occupational and professional gap is a vacuum and too huge to be ignored by both insurance industry and health-care provider industry. A new occupation or profession has to be developed to handle such huge crisis: ERISA health-care Claim Specialists and Department, to bridge the gap FROM medical coders and billers & insurance claim processors TO lawyers.

 

Any traditional and conventional appeals without ERISA COMPLIANCE are "squeaky wheel appeals" for any ERISA claim denials and delays, 80 percent of U.S. Healthcare claims and 60% of U.S. Healthcare expenditure.

Only appeals with
full ERISA compliance will ensure maximum reimbursement or crisis turnaround at minimum cost and frustrations.

 

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)

 

Aetna (DOL/ERISA) and 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!

 

"Congress library report", "Minneapolis memorandum" and "Phoenix memorandum" should have been sufficient intelligence for executive decision-making on health-care Oct. 11 fact card.

 

In today's progressively worsening health-care and budget crisis since World War II, any health-care executive strategy, without mastering or complying with ERISA, has been proven failing since inception of managed care practice, unless a new health-care reimbursement and compliance model is established and implemented to immediately create a new line of ERISA reimbursement personnels and occupation, "ERISA Healthcare Claim Appeals and Reimbursement Specialists and Departments", no one in this country can stop and survive our failing health care system crisis.

 

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..

 

Contrary to the popular belief, the 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.

 

"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.

 

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

 

Any reimbursement strategy will be incomplete under current ERISA statutory and managed care environment unless ERISA appeal division and specialists are included in your reimbursement practice, as important as billers and coders, office manager, and consumer account manager, or even CFO's were initially included in your business and industry.

 

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)]  

 

bullet

"medical doctors in Texas" = MD licensed to practice medicine in Texas for a Texas ERISA case;

bullet

"a medical professional in the relevant area" = relevant area of state laws in license jurisdiction, scope of practice and relevant local standard of care;

bullet

"licensed" = licensed by the State Government/licensing board;

bullet

"to perform" = to practice medicine or health care services in the State;

bullet

"specified health services" = medical procedures or services being reviewed or denied, instead of file review or insurance coverage reviews services;

bullet

"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).

 

    U.S. Supreme Court visited ERISAclaim.com in regard to ERISA § 2560.503-1(h) at 11:57:03 AM on Friday, November 21, 2003 for this No. one point. Click here for more coverage of Supreme Court Visiting at ERISAClaim.com.

 

 

Please e-mail for details

 

 

 

 

 

Why An Appeal Department???

 

  1. Now you have done your best for your coding and billing practice;

  2. Now you have done your best for your managed care contracting;

  3. Now you have done your best for your legislation for protections;

  4. Now you have done your best for cost & expenses cutting;

  5. Now you have done your best in patient debt collections.

 

Your hospital or practice is still losing money!!!

 

You must have an Appeal Department for all of your delayed and denied claims

 

You must have New Claim Appeal Specialists

for all of your delayed and denied claims

 

We can help you to create an Appeal Department

in your hospital or practice

 

On-Site & In-House

 

If

 

1. You deal with Medicare Claims

 

AND

 

2.  You deal with health insurance claims in private sector,

you must comply with ERISA, a federal law,

according to U.S. Supreme Court ruling on 06-21-2004

 

For CFO's, COOs, Denial Management Dept.,
Managed Care Directors,  Contract Managers,
A/R Specialist, Reimbursement Manager,
Office Manager, Coder's/Biller's,

Patient Accounting Directors And Managers,
Risk Managers, Revenue Cycle Directors,
Claims/ Benefit Managers,

"Provider Sponsored Organization" of HMO's, IPA's &
"Integrated Health Systems/Networks"
Providers, Payers And Suppliers,
Employer, Insurer, TPA's,
Appeals Dept., HR,

and More.....

 

Dr. Jin Zhou Will Speak at This 2007 National Conference



 

World Research Group has also organized two in-depth workshops conducted by the industry’s thought leaders that will drill down into the solutions you need to prevent, reduce and overturn denials. Register for both to maximize your on-site learning experience.

 

Don’t Miss these Must-Attend, In-Depth Workshops!
bullet Mastering the Medicare & ERISA Appeal Process: Maximum Reimbursement through Compliance
ERISAclaim.COM
bulletThe Denial Diagnosis Tool Kit: A Claim-by-Claim Action Guide to Integrating Technical, Clinical, Legal and (sometimes) Political Perspectives in Managing Denials
ADVANCED REIMBURSEMENT MANAGEMENT

links to registration: http://worldrg.com/showConference.cfm?confcode=HW765
 

For a brochure, click here 

 
4th Annual Optimizing Managed Care Contracting for Hospitals
September 19 - 20, 2007
Chicago, IL
Register   •  
Download a Brochure
 

 

 

Hospital CEO's Confessed Their Biggest Headaches:

Financial Challenges from Unpaid/Denied Medical Bills in 2004

 

71% of CEO's, out of 460 surveyed by American College of Healthcare Executives (ACHE) in 2004, identified No. 1 headache, among other things, as financial challenges. Top 5 problems of financial troubles:  Medicaid 78%, Bad Debt 72%, Medicare 70%, Revenue Cycle Management 53% and Managed-care Payments 52%. Care for the uninsured and personnel shortage were ranked as No. 2 and No. 3 pressing issues. For more details, go to ACHE's Top Issues Confronting Hospitals: 2004

Dr. Jin Zhou, President of ERISAclaim.Com, has strongly advocated for the Hospital CEO's and the entire health care industry to utilize and comply with the superpower of ERISA, federal law, governing health care denials and to create a new line of occupation, claim appeals specialist, to cope with industry claim denial crisis, soon to be tripled in 2005.

 

Getting paid through ERISA compliance instead of abuse and fraud.

OIG: Special Advisory Bulletin: Practices of Business Consultants [PDF]  Testimony of Lewis Morris [PDF]
[http://oig.hhs.gov/fraud/docs/alertsandbulletins/consultants.pdf]
The Office of Inspector General (OIG), Department of Health and Human Services
, June, 2001

 

 

Conclusion or Confusion?

© 2005, Jin Zhou, ERISAclaim.com

 

ERISAclaim.com - CMS New Appeal Rules: "Overhaul of the Medicare Claims Appeals System"

 

"Based on our comprehensive and diligent study of this new Medicare appeal process, and our extensive experience in ERISA claim procedure practice, and "in view of the wide span of applicability of these rules and the complex, intertwined nature of the affected appeal procedures," [page 2 of 511] it is our conclusion that our nation must recognize and create a new profession, separated from and/or in addition to traditional Coding and Billing personal:

 

"Medicare Appeals Specialist"

 

Guerrilla and weekend training without systematic and quality education will definitely fail in Medicare reimbursement because of its broad requirement and "Authorized Representative" practice with "a waiver of the assignee's right to collect payment...."

 

"Medicare Appeals Specialist" and "ERISA Claims Specialist" will be the crown of US healthcare reimbursement.

 

This is why Congress and CMS created QIC (="Appeal Specialists" with dual and "sufficient medical, legal, and other expertise", § 405.968 (c) (1) [page 394 of 511]) separated FROM and in addition to Medicare Claim Processors (Medicare FI's & Carriers), (Among the major changes required by the BIPA amendments are--......Requiring the establishment of a new appeals entity, the qualified independent contractor (QIC), to conduct “reconsiderations” of contractors’ initial determinations (including redeterminations, [page 15-16 0f 511]).

 

And this is also why Congress enacted ERISA 30 years ago to require "an appropriate named fiduciary of the plan", § 2560.503-1(h) (1), rather than a claim processor or ASO (Administrative Services Only) TPA (Third-Party Administrator) to handle ERISA health claim appeals.

 

Conclusion or Confusion? Your choice and decision."

 

Jin Zhou, ERISAclaim.com, 03/08/2005

 

 

 

 

The First & Only One in the Country
ERISA Claims Procedure
Comprehensive Modular
Educational Training Programs
For Every One Who Handles ERISA Healthcare Claims 

 

For Maximum Reimbursement through ERISA Compliance
For Reimbursement/Financial Crisis Turnaround

All National and Regional Major Accounts Will Require
ERISA Compliance by The Plan TPA's (ASO's)


To Become Nation's First Generation of

ERISA Healthcare Claim Appeals and
Reimbursement Specialists

 First ERISA Denial Management Department
For Your Hospital & Practice

 

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

Schedules & Locations Are Forthcoming
Please e-mail for further notice & details

 

For Maximum Reimbursement through ERISA Compliance
For Reimbursement/Financial Crisis Turnaround

To Become Nation's First Generation of

ERISA Healthcare Claim Appeals and
Reimbursement Specialists
 First ERISA Denial Management Departments

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

 

Managed-Care Claim Delays & Denials? What Does an Unanimous US Supreme Court Say?

 

On June 21, 2004, an unanimous US Supreme Court ruled that claim processing (medical judgment, timely pay &  benefits determination)  and denials of benefits under the employer-sponsored health plans, ERISA-regulated benefit plans, for both self-insured and fully-insured (through purchase of insurance) health plans, are completely governed by federal law ERISA, that supersedes and invalidates state laws.

 

ERISAclaim.com: "employer-sponsored group health plans" = "ERISA-regulated benefit plans", both self-insured and fully-insured (through purchase of insurance) health plans, (ERISA - Title 29, Chapter 18.  Sec. 1002.)

 

ERISAclaim.com - Supreme Court Managed Care ERISA Watch

 

An Unanimous U.S. Supreme Court Ruling in

Managed Care and Medical Malpractice

 

Aetna Health Inc. v. Davila

06/21/04

Opinion of the Court

 

"Held: Respondents’ state causes of action fall within ERISA§502(a)(1)(B), and are therefore completely pre-empted by ERISA §502 and removable to federal court. Pp. 4–20."

 

"We hold that respondents’ causes of action, brought to remedy only the denial of benefits under ERISA-regulated benefit plans, fall within the scope of, and are completely pre-empted by, ERISA §502(a)(1)(B), and thus removable to federal district court. The judgment of the Court of Appeals is reversed, and the cases are remanded for further proceedings consistent with this opinion.7 It is so ordered."

 

 

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.

 

A Consumer Guide to Handling Disputes with Your Employer or Private Health Plan -- 2005 Update (Kaiser Family Foundation)

 

What You Need to Know About Your Employer-Sponsored Coverage

"If you are enrolled in an employer-sponsored health plan, your right to appeal disagreements about benefits through your plan’s internal appeals process is determined by federal law (the Employee Retirement Income Security Act, or ERISA) and a federal ERISA regulation that became effective January 1, 2003." 

Full Report (pdf)

 

USNews.com: Health: In Brief: Public Health: Winning fights with your HMO (8/12/05)

 

 

 

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) & baltimoresun.com - Health plan 'stings' on rise

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."

Blue Cross and Blue Shield Association Announces New Strike Force to Protect American Consumers from Fraud and Fight Rising Costs (U.S. Newswire, 4/19/2004)

"DETROIT, April 19 /U.S. Newswire/ -- The Blue Cross and Blue Shield Association (BCBSA) today announced a new Anti-Fraud Strike Force comprised of top Blue Plan investigators that will work with the Federal Bureau of Investigation (FBI) and other national, state and local law enforcement agencies to fight major insurance fraud schemes that rob consumers of millions of dollars annually. BCBSA President and CEO Scott P. Serota announced the new initiative in a speech to the Detroit Economic Club."

 

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"

 

"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."

GAO: HEALTH CARE Consultants’ Billing Advice May Lead to Improperly Paid Insurance Claims, June 2001

"In summary, the two workshops about which we raise issues in this report offered in-depth discussions of regulations that pertain to billing for evaluation and management health care services2 and compliance with health care laws and regulations. During the course of discussions at those workshops, certain advice was provided that is inconsistent with guidance provided by the Department of Health and Human Services’ Office of Inspector General (OIG). Such advice could result in violations of both civil and criminal statutes. Specifically, certain consultants advocated not reporting or refunding overpayments received from insurance carriers after they were discovered. The consultants also encouraged the performance of tests and procedures that are not medically necessary to generate documentation in support of bills for evaluation and management services at a higher level of complexity than actually confronted during patients’ office visits. ...."

 
 

 

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."

Employers Audit Workers' Health Claims (Wall Street Journal via SFGate.com) & (MLive.com, MI)

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."

USATODAY.com - Hospitals Sock Uninsured with Much Bigger Bills

GM to Report $60B in Future Health-Care Obligations

 

 


Payments Go Under a Microscope (washingtonpost.com)

January 12, 2004

"CareFirst officials said the audit of 2,800 doctors was triggered by an earlier examination of several thousand claims that found 9 of every 10 were inaccurate. "The doctors, we're not saying we don't trust them," said Jeff Valentine, a CareFirst spokesman. "But as President Reagan said a number of years ago: 'Trust, but verify.' "

"The largest insurer of all, the federal government, recently estimated that the Medicare program overpaid doctors, hospitals and other health-care providers by $11.6 billion in 2002, according to an audit of 128,000 claims. The audit found many providers submitted insufficient documentation (45 percent), billed for medically unnecessary services (22 percent) and used incorrect codes to describe patient visits (12 percent)."

"A larger audit is planned this year. "The digging now is much deeper," said Leslie V. Norwalk, chief operating officer of the Centers for Medicare & Medicaid Services, the government agency known as CMS. "Any dollar overpaid is a dollar too much."

"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."

"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."

.....

"It is the responsibility of an independent reviewer to be alert to fraud and abuse and certainly not to ignore it," said Meehan. "In this case, as the complaint alleges, Ernst & Young kept itself deliberately ignorant of the facts."

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."

Labor Department Sues Corporation For Violating Federal Employee Benefit Law (Release Date: 02/02/2004)

Are All Consultants Corrupt? (Fast Company)

Excerpt: "That's one possible conclusion in the wake of the Enron scandal. According to David Maister, who's been studying professional-services firms for more than 20 years, it's time to clear the air."

Effective Corporate Compliance Programs for Health Care Organizations (pdf) (Ernst & Young)

"An executive summary to our 52-page overview of the government's efforts to detect and punish health care fraud and abuse, with guidelines on how organizations can develop an effective corporate compliance program. (Adobe Acrobat - 708K)

Strengthening Ethical Cultures: The Emerging Role of Compliance Programs and Officers in Managed Care Organizations (Ernst & Young)

 

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.

 

Department of Labor

"A group health plan is an employee welfare benefit plan established or maintained by an employer or by an employee organization (such as a union), or both, that provides medical care for participants or their dependents directly or through insurance, reimbursement, or otherwise.
 

Most private sector health plans are covered by the Employee Retirement Income Security Act (ERISA). Among other things, ERISA provides protections for participants and beneficiaries in employee benefit plans (participant rights), including providing access to plan information. Also, those individuals who manage plans (and other fiduciaries) must meet certain standards of conduct under the fiduciary responsibilities specified in the law."

 

 

 

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

 

US Code Home

CHAPTER 18--EMPLOYEE RETIREMENT INCOME SECURITY PROGRAM

 

 

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 & Claim

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 ERISA Settlemnt with 950,000 MD's

 

 

ERISA Laws/Rules

ERISA in the United States Code: Cross-reference table, table of contents

 

 

 

 

 

 

 
Working Families' Health Insurance Coverage, 1997-2001 (Center for Studying Health System Change)
 

"Of the 189 million nonelderly people in working families in 2001, 77.5 percent, or 146 million, had employer coverage,.."

 

 

 

 

Opinion: The Coming Crash in Health Care (Fortune.com)
"Thus it may come as a surprise to learn that the managed-care industry is dying. Oops, did we spill the beans so soon? Well, so be it. Managed care is on the way out."

 

 

 

Managed Care and Patients' Rights
(JAMA Editorial)

 

 

Enrollee Appeals of Preservice Coverage Denials at 2 Health Maintenance Organizations (JAMA Abstract)

 

 

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)

 

 

University faces $2M in health care debt

"Nowak said a big part of the medical care issue is education for all people affected by it, which is a top priority of the HCC."

 

 

Cash-poor UCLA hospitals hire turnaround firm  (Los Angeles Times)
"Turnaround firm is asked to increase efficiency and cut costs for the system, which fiscally lags far behind its UC counterparts."

"The largest medical system in the UC chain, UCLA Healthcare reported lower net income than its sister campuses last fiscal year and as of Dec. 31 had only $20,000 cash. By comparison, UC Davis had $183 million in cash, the most systemwide.

UCLA Healthcare -- which includes two hospitals in Westwood and one in Santa Monica -- was forced to borrow $7 million in December from the UCLA chancellor's office to help pay bills."


 

 

Federal Employees Health Benefits Program

FEHB HANDBOOK

 

 


 


 

 

2003 Segal Health Plan Cost Trend Survey: Preliminary Findings (PDF) (The Segal Company)

 

Tiered Hospital Plans (07/29/2003) (

 

Tiered Networks for Hospital and Physician Health Care Services (Employee Benefit Research Institute)

 

Retiree Health Care Benefits: Data Collection Issues (07/29/2003)

 

Facts from EBRI: Health Insurance and the Elderly (PDF) (Employee Benefit Research Institute)

Excerpt: "In 2001, 32.2 percent of the elderly had employment-based health insurance coverage in addition to Medicare, up from 28.7 percent in 1987." (page 2)

 

the Foundation for Health Coverage Education (The Foundation for Health Coverage Education)

 

 

US Department of Justice Seal

USDOJ

 Office of the Deputy Attorney General:

Publications and Documents

bullet The Health Care Fraud and Abuse Control Program FY 2002
bullet The Health Care Fraud and Abuse Control Program FY 2001
bullet The Health Care Fraud and Abuse Control Program FY 2000
bullet The Health Care Fraud and Abuse Control Program FY 1999
bullet The Health Care Fraud and Abuse Control Program FY 1998
bullet Health Care Fraud Report, Fiscal Year 1998
bullet Health Care Fraud Report, Fiscal Year 1997

USDOJ: DAG: Corporate Fraud Task Force

Federal Bureau of Investigation - Health Care Fraud Unit  

FBI: About the Health Care Fraud Unit

VideoVIDEO

Link to Site Map

Fighting Fraud & Abuse

 
bullet What is Medicare fraud?
bullet How do you recognize it? Fraud Tips
bullet How do you report it?
bullet Recent schemes and scams uncovered by Medicare (alerts)

 

Program Integrity Manual (PIM)

Examples of Fraudulent Activities
 pdf | word |

 

HHS-Office of Inspector General (OIG)

 

HHS-OIG-What's New

HHS-OIG-Fraud Prevention & Detection

HHS-OIG - Publications

 

 

 

Federal Employees Health Benefits Program

FEHB HANDBOOK

 

 

 

 

 

 

 

Former uninsured patients alleged predatory collections

Chicagobusiness.com
 

Fraud Recovery and Prevention Efforts Net Over $7.5 Million

 

FAQ/Glossary, Member Services, Preferred Health Network, PHN Online,( CareFirst BlueChoice, Inc.)

DOL ERISA Talking Points

(BCBSCNY)

 

BCBS 2004 Edu Programs (pdf)

 

BCBS2003 Edu Programs (pdf)


Washington Post Examines Health Plans' Increased Scrutiny of Healthcare Providers' Claims (KaiserNetwork.org)

 

ABCNEWS.com : Huge Medical Insurance Scam Alleged

"Rarely does the FBI discuss an ongoing investigation. But the agency made an exception because this scam is so big. Insurance companies have already been hit with half a billion dollars in claims."

 

CNN.com -Transcripts:

A New Plan to Fight Terrorism? A look at Healthcare Fraud

 

Rent a Patient - Fraud Scheme

(BCBSAL)

 

KSAT.com - Health - 'Rent-A-Patient' Fraud Under Investigation

"UnitedHealth Group alone said it's told the FBI about 300 allegedly fraudulent Southern California centers."

 

State of Wisconsin - DOJ News Release

Lautenschlager Announces Public Alert on "Rent a Patient" Insurance Scams Victimizing Wisconsin Citizens and Businesses

 

Outpatient surgery centers probed for fraud (San Jose Mercury News, CA)

 

'Rent-A-Patient' Fraud Under Investigation
(NBC4.TV, CA)

 

New Boston podiatrists accused of insurance fraud (AP Wire | 03/11/2004)

 

TWO ACCUSED IN NEW BOSTON MEDICAL SCAM

(Tyler Morning Telegraph)

 

USDOJ: Deputy

Attorney General: Publications and Documents - - Health Care Fraud Report Fiscal Year 1998

 

Payments Go Under a Microscope (washingtonpost.com)

 

CMS: Comprehensive Error Rate Testing (CERT) Program

 

(January 15 , 2004)

 

RECOVERY room
(MLive.com)

 

USATODAY.com - Hospitals sock uninsured with much bigger bills

A Booster Shot for Uninsured

"Illinois hospitals are hammering out a plan to provide free or discounted care to the uninsured"

 

Hospital group examines plan for free care (Chicagobusiness.com)

""Aggressive collection tactics with uninsured patients cost a non-profit hospital in Urbana its tax-exempt status last month. Illinois Attorney General Lisa Madigan is investigating hospitals’ dealings with the uninsured, and a Chicago alderman is talking about revoking tax breaks for hospitals that limit charity care."

 

Doctor 'scorecards' are proposed (The Wall Street Journal)

 

Bureau of Justice Statistics Medical Malpractice Trials and Verdicts in Large Counties, 2001  (Acrobat file) (Press release)

 

Staying Out of Jail Under ERISA's Bulked-Up Criminal Law Penalites (Attorneys Russell D. Shurtz and Craig R. Pett)

 

 

FDA Logo links to FDA home page

New Super Search

 

 

 

FDA > CDRH > Database Super Search

 

"Device Listing Database

 

Proprietary Device Name:

MASSAGER ( THERAPUTIC, ELECTRIC, WATER

Common/Generic Device Name:

ASOOTHE/AQUAMED

Classification Name:

MASSAGER, THERAPEUTIC, ELECTRIC

Device Class:

1

Product Code:

ISA

Regulation Number:

890.5660

Medical Specialty:

Physical Medicine"

 

Categorization of Investigational Devices

 

"... all FDA-approved IDE's into either Category A (experimental / investigational) or Category
B (nonexperimental/ investigational). An experimental / investigational ..."

 

 

 

 

Agree to terms and conditions

"Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply."

 

CIGNA - Coverage Positions/Criteria
"The terms of a participant's particular benefit plan document [Group Service Agreement (GSA), Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Positions are based. If these Coverage Positions are inconsistent with the terms of the member's specific benefit plan, then the terms of the member's specific benefit plan always control."

 

UnitedHealthcare Medical Policies

"By clicking "I agree," you agree to be bound by the terms and conditions expressed below, in addition to our Site Use Agreement.

UnitedHealthcare medical policies have been made available to you as a general reference resource. When reading these policies you agree that:

Our Medical Policy is not your patient's Benefit Plan.

Your patient's medical benefits are governed and determined by a benefit document, either a Certificate of Coverage or a Summary Plan Description. You should not rely on the information contained in this Web site section to determine your patient's medical benefits.
 

  1. Federal and state mandates and the patient’s benefit document take precedence over these policies.

  2. The patient’s benefit document lists the specific services that have coverage limits or exclusions.


Our Medical Policy does not address every situation and individuals should always consult their physician before making any decisions on medical care."


Medical Necessity: The Gateway to Meaningful Health Care Access (Rosenfeld & Rafik)

 

The Independent Medical Review Program (insurance.ca.gov)

 

 

 

 
   

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