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Pension and Employee Benefit Law

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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

DOL Seal - Link to DOL Home Page

UNITED STATES

DEPARTMENT OF LABOR

(Links to DOL) ©2010, Jin Zhou, ERISAclaim.com

Patient Protection and Affordable Care Act

Statutory Laws [PDF] [PDF]

 

 

Employee Retirement Income Security Act — ERISA

 

Webinars, Seminars & Certification Classes for New Federal Health Claim Appeals Regulations

 

ERISAclaim.com - Free Webinars - New Federal Claims & Appeals Regulations, Effective Sept. 23, 2010, for 193 Million Americans

 

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

 

ERISAclaim.com - 2010 PPACA & ERISA Claim Specialist Certification Programs in Chicago, Illinois

 

ERISAclaim.com:  Create An Appeal Department for Your Hospital or Practice (In-house, onsite ERISA Claim Specialist Certification Programs)

 

 

ERISAclaim.com Press Release

 

FOR IMMEDIATE RELEASE: 

ERISAclaim.com Announced the Expansion of Its ERISA Litigation Support For the Healthcare Claims In Response to Increasing High Demand from the $6 Trillion Healthcare Denial Management Market. 10-19-2009, Hanover Park, IL

 

ERISA Litigation Support

 

Facts + Laws + Strategies = Winning When Inevitable

 

      In light of increasing managed-care litigation under ERISA and  RICO on behalf of healthcare providers in an era of skyrocketing healthcare costs in the midst of unprecedented economic recession, ERISAclaim.com is expanding its long-standing ERISA consulting and litigation support divisions and services for more law firms.

 

      ERISAclaim.com  has been the only company that provides most systematic and comprehensive ERISA claim appeals education, consulting and litigation support for and on behalf of healthcare providers and hospitals, when ERISA, as a part of federal law, was the most misunderstood governing laws for healthcare claims, and more than 55% of US healthcare expenditure for almost $2 trillion each year, therefore, ERISA might be the most complicated law in the United States.

 

    Dr. Jin Zhou, the president of ERISAclaim.com developed the first ERISA education and practical appeal system for healthcare providers and has gained most comprehensive and unique experience in  practical field ordeals navigating ERISA landscape in U.S. healthcare reimbursement wonderland, sometimes, Dr. Jin Zhou was referred to as the "Godfather of ERISA Claims" for healthcare providers by some industry experts, his ERISA expertise and experience are unique and different from that in traditional ERISA appeal and litigation for disability claims on behalf of patients instead of healthcare providers with billing and coding, medical necessity and managed-care contracting and network complications.

 

ERISAclaim.com offers litigation support services including but not limited to the following:

 

  1. How to Effectively Secure Legal Standing for Healthcare Providers As an Authorized Representative to Appeal and to Pursue Legal Actions in Federal Court On Behalf Of the Patients;

  2. How to Effectively and Strategically Exhaust Appeal Administrative Remedies under ERISA.

  3. How to Identify Relevant Plan Administrators and Plan Fiduciaries under ERISA in the Jungle of Managed-care  "Dizzyland".

  4. How to Effectively Conduct and Complete True ERISA Appeals among Complexed Medical and Insurance Billing and Coding, Medical Necessity and Managed Care Contracting Disputes

  5. ERISA Health Care Claim Research Assistance

  6. ERISA Appeal and Litigation Strategies, Most Unique "Art of War" Winning Strategies

  7. ERISA Litigation Networking, for Potential ERISA Matchmaking Between Healthcare Providers and Healthcare Attorneys. 

  8. Service Fees Ranging from the  Case Complexity and Quantities, Based on Per Hourly Fees and Task Fees, Please Contact Us for Details.

 

      ERISAclaim.com advocates for compliant ERISA appeals as administrative remedies before any litigations by healthcare providers and patients to avoid any costly and lengthy litigations, however when ERISA litigation becomes inevitable even with good faith ERISA appeals completely exhausted, intentional noncompliance or reckless violation of ERISA claim regulation by ERISA plans, we believe that the successful "ERISA-accurate"  completion and exhaustion of ERISA administrative remedies based on accurate and objective facts under  superb "Art of War" Strategies will Ensure the most likelihood of  winning for the inevitable litigations.

 

      If you have any questions or need our assistance, please contact Dr. Jin Zhou, the president of the ERISAclaim.com at ERISAclaim@aol.com.

 

Jin Zhou

President

www.ERISAclaim.com

630-736-2974 (office)

630-808-7237 (mobile)

 

October 10, 2009

 

Free Litigation Support - Related Links and Resources:

 

ERISAclaim.com - Supreme Court Managed Care ERISA Watch

 

ERISAclaim.com - Managed Care Court Watch - Superpower & Protections for Physicians

 

ERISAclaim.com - 950,000 MD's Settled With Aetna & Cigna on ERISA

 

ERISAClaim.com: DOL Final Rules - The Rule of the Game for 80% of Healthcare Claims in the U.S.

 

 

ERISAclaim.com - ERISA or PPO? Managed Care Slavery or ERISA Superhero

 

ERISAclaim.com - ERISA for Hospital Reimbursement Turnaround

 

ERISAclaim.com - ERISA for Medical Device Makers & Surgeons

 

ERISA Appeals or Lawsuit with PPO Contract or Class-Action Settlement

 

ERISAclaim.com - "Overpayment" Refund Request Response & Appeals

 

 ERISA law governs both self-insured and fully-insured/funded ("through purchase insurance") health plans sponsored by employers in private sector. ERISA statutory definition, 29USC1002, from the U.S. Code Online via GPO Access: (Click here)

 

<http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=browse_usc&docid=Cite:+29USC1002>

 

"From the U.S. Code Online via GPO Access
[www.gpoaccess.gov]
[Laws in effect as of January 3, 2007]
[CITE: 29USC1002]


[Page 312-321]


                             TITLE 29--LABOR
         CHAPTER 18--EMPLOYEE RETIREMENT INCOME SECURITY PROGRAM
            SUBCHAPTER I--PROTECTION OF EMPLOYEE BENEFIT RIGHTS
                      Subtitle A--General Provisions
 

Sec. 1002. Definitions


    For purposes of this subchapter:


    (1) The terms ``employee welfare benefit plan'' and ``welfare plan'' mean any plan, fund, or program which was heretofore or is hereafter established or maintained by an employer or by an employee organization, or by both, to the extent that such plan, fund, or program was  established or is maintained for the purpose of providing for its participants or their beneficiaries, through the purchase of insurance or otherwise, (A) medical, surgical, or hospital care or benefits, or benefits in the event of sickness, accident, disability, death or unemployment, or vacation benefits, apprenticeship or other training programs, or day care centers, scholarship funds, or prepaid legal services, or (B) any benefit described in section 186(c) of this title (other than pensions on retirement or death, and insurance to provide such pensions)......." [[Page 313]]

 

 

DOL ERISA FAQ’s

<http://www.dol.gov/ebsa/faqs/faq_claims_proc_reg.html>

 

DOL ERSA FAQs About The Benefit Claims Procedure Regulation

B-2: Does an assignment of benefits by a claimant to a health care provider constitute the designation of an authorized representative?

 

No. An assignment of benefits by a claimant is generally limited to assignment of the claimant’s right to receive a benefit payment under the terms of the plan. Typically, assignments are not a grant of authority to act on a claimant’s behalf in pursuing and appealing a benefit determination under a plan. In addition, the validity of a designation of an authorized representative will depend on whether the designation has been made in accordance with the procedures established by the plan, if any.

 

B-3: When a claimant has properly authorized a representative to act on his or her behalf, is the plan required to provide benefit determinations and other notifications to the authorized representative, the claimant, or both?

 

Nothing in the regulation precludes a plan from communicating with both the claimant and the claimant’s authorized representative. However, it is the view of the department that, for purposes of the claims procedure rules, when a claimant clearly designates an authorized representative to act and receive notices on his or her behalf with respect to a claim, the plan should, in the absence of a contrary direction from the claimant, direct all information and notifications to which the claimant is otherwise entitled to the representative authorized to act on the claimant’s behalf with respect to that aspect of the claim (e.g., initial determination, request for documents, appeal, etc.). In this regard, it is important that both claimants and plans understand and make clear the extent to which an authorized representative will be acting on behalf of the claimant.

 

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

 

NBC 10 Breaking News:

Overpayment - FBI - Class Action

"Biggest Fraud in US History"

NBC10 Video

Blue Cross sues doctor over payments 


NARRAGANSETT, R.I. -- Just two days after a Narragansett doctor leveled strong accusations against Blue Cross & Blue Shield of Rhode Island, he learned he was being sued. Blue Cross filed a $100,000 lawsuit against Dr. Jay Korsen for damages caused by his going public with his complaints. - turnto10.com - Jun 19, 2009

 

Doctor claims Blue Cross withheld payments 


http://www.turnto10.com/jar/news/local/article/doctor_says_bcbs/14643/
A local chiropractor says he was strong armed by Blue Cross & Blue Shield of Rhode Island. The Narrangansett doctor says Blue Cross withheld money from him and he charges them with intimidation. -  turnto10.com - Jun 17, 2009

 

Pomerantz Files Class Action Against Blue Cross Blue Shield Association

 

Sept. 10, 2009

"Pomerantz filed a class action lawsuit against the Blue Cross Blue Shield Association ("BCBSA") and 22 leading BCBS insurers across the country on behalf of a putative nationwide class of health care providers, as well as the Pennsylvania Chiropractic Association ("PCA"), the New York Chiropractic Council (the "Council"), and the Association of New Jersey Chiropractors ("ANJC"). The suit challenges the Defendants' abusive practices in using post-payment audits and reviews, and improper repayment demands, to pressure providers to repay substantial sums that have previously properly been paid as health insurance benefits for services provided to BCBS subscribers."

For a copy of the BCBSA Complaint, click here

 

 

 

Pomerantz Files Class Action Against Blue Cross Blue Shield Association ("BCBSA") and Related BCBSA Entities

Reuters, Thu Sep 10, 2009 6:11pm EDT

 

CHICAGO--(Business Wire)--

"Pomerantz Haudek Grossman & Gross LLP today announced that it and co-counsel Buttaci & Leardi, LLC filed a class action lawsuit against the Blue Cross Blue Shield Association ("BCBSA") and 22 leading BCBS insurers across the country on behalf of a putative nationwide class of health care providers, as well as the Pennsylvania Chiropractic Association ("PCA"), the New York Chiropractic Council (the "Council"), and the Association of New Jersey Chiropractors ("ANJC"). The suit challenges the Defendants` abusive practices in using post-payment audits and reviews, and improper repayment demands, to pressure providers to repay substantial sums that have previously properly been paid as health insurance benefits for services provided to BCBS subscribers.

 

......In making the appointment, the Court stressed the significant role Pomerantz had played in a $249 million settlement of its UCR class action against Health Net, stating that the Court had "similarly appointed Pomerantz to be Plaintiffs` spokesman to the Court in the Health Net litigation because the Court found D. Brian Hufford, Esq. to be the attorney most capable of presenting Plaintiffs` position in a clear and concise manner." In re Aetna UCR Litig., 2009 Dist. LEXIS 66853, *8 n.4 (D.N.J. July 31, 2009)."

For a copy of the BCBSA Complaint, click here

 

Pomerantz Files Class Action Against Aetna (News from Pomerantz)

 

For a Copy of the Official Complaint, click here

 

Pomerantz Files Class Action Suit Against Aetna On Behalf of Healthcare Providers to Challenge Abusive Post-Payment Audit Practices (GlobeNewsWire, press release)

"NEWARK, N.J., July 29, 2009 (GLOBE NEWSWIRE) -- Pomerantz Haudek Grossman & Gross LLP today announced that it and co-counsel Buttaci & Leardi, LLC, have filed a class action lawsuit against Aetna, Inc., and its various health insurance subsidiaries on behalf of a putative nationwide class of health care providers, the Association of New Jersey Chiropractors ("ANJC") and the New York Chiropractic Council ("NYCC"). The suit challenges Aetna's abusive practices in using post-payment audits, with false allegations of fraud, to pressure providers to repay substantial sums that have previously properly been paid for providing services to Aetna subscribers.

The action alleges that Aetna's post-payment audit process violates the Employee Retirement Income Security Act of 1974 ("ERISA"), in that its repayment demands are retroactive determinations that particular services are not covered under the terms of Aetna's health care plans, but without any of the appeal or other protections otherwise available under ERISA for both self-funded and fully insured health care plans offered through private employers. The complaint further alleges that both the post-payment audit process and the pre-payment claim review process employed by Aetna to strong-arm chiropractors into unfavorable settlements violate the Racketeer Influenced and Corrupt Organizations Act ("RICO"). In addition to challenging the process by which Aetna pursues and applies its audits, the complaint also challenges numerous clinical policy bulletins of Aetna, which are used to deny services retroactively without adequate basis or clinical support."

What’s Next: The Plaintiff’s Perspective – Healthcare Insurers Face Explosive New Cause of Action « BulletProofblog.com>>

Authored By: Larry Smith September 16, 2009

"In this regular feature, Bulletproof interviews top plaintiffs' attorneys for their perspective on the crises likely to affect businesses in the near future. Today we talk to D. Brian Hufford, partner in the Columbus, Ohio office of the pioneering class action firm Pomerantz Haudek Grossman & Gross LLP. Mr. Hufford has just filed a class action against the Blue Cross Blue Shield Association and 22 BCBS insurers across the country on behalf of providers and professional chiropractic associations in Pennsylvania, New York, and New Jersey."

ERISAclaim.com - "Overpayment" Refund Request Response & Appeals

BCBSA News, June 30, 2009

Blue Cross And Blue Shield Companies' Anti-Fraud Efforts Recover $350 Million In 2008

"WASHINGTON – Blue Cross and Blue Shield companies' anti-fraud investigations resulted in overall savings and recoveries of nearly $350 million in 2008, an increase of 43 percent from 2007, according to data released today by the Blue Cross and Blue Shield Association (BCBSA) National Anti-fraud Department (NAFD).  From 2007 to 2008, the number of cases opened increased nearly 34 percent, and the closed cases increased about 43 percent."

AMNews: July 6, 2009. Tennessee Medical Assn. sues collections firm
Health Research Insights has contacted physicians in several states this year trying to collect alleged overpayments.

 

For A Copy of TMA v. HRI Lawsuit, click here
 

AMNews: May 18, 2009. State medical societies strategize against collector
Legal action is one option against Health Research Insights.
 

AMNews: May 11, 2009. Company stops tapping physicians for 'overpayments'
Doctors protested self-insured Georgia-Pacific's attempt to collect refunds of suspected claims upcoding.
 

AMNews: April 13, 2009. Self-insured companies going after doctors to recover 'overpaid' claims
There is no clear time limit on how far back ERISA-protected companies can go to recoup money. One company is turning that into a business.

 

Overpayment Demand Letter from HRI:

"Dear Health Care Professional,

 

......You must take action as outlined in items (1) or (2) above, in order to ensure compliance with the Employee Retirement Income Security Act of 1974 (ERISA). ERISA is the federal law that, among other things, governs health benefit plans in private industry. Investigation of potential ERISA violations is given to the United States Secretary of Labor pursuant to sections 504 and 506 as amended by the Comprehensive Crime Control Act of 1984 and enforced by the US Department of Labor.

 

In the event HRI is not contacted by you or your designee, a Complaint may be filed with the Employee Benefits Security Administration (EBSA). You may view additional information at (www.dol.gov/ebsa)."

Physicians Strike Back At Employers' Collection Firms ( BNET Healthcare Blog | BNET)

"In the most recent clash, the Tennessee Medical Association has sued Health Research Insights (HRI), a Franklin, TN-based firm that has sent collection letters to physicians in Georgia, Kentucky, Tennessee and Texas. Other defendants in the suit include the Metropolitan Government of Nashville and Davidson County, TN, and Nashville’s Board of Education, which runs a self-insured plan for school employees. Blue Cross and Blue Shield of Tennessee, the plan’s administrator, is also named in the suit, although the insurer disavows any relationship with the collection firm.

 

The suit, which alleges fraud, says that HRI keeps 40 percent of whatever it collects. The TMA wants a court to enjoin HRI from making any further efforts to collect from physicians. An earlier protest by the Georgia Medical Society against HRI’s work on behalf of Georgia Pacific led to a suspension of those activities."

Employment-Based Health Coverage and Health Reform: Selected Legal Considerations (PDF) (U.S. Congressional Research Service)

"It is estimated that nearly 170 million individuals have employer-based health coverage. As part of a comprehensive health care reform effort, there has been support (including from the Obama Administration) in enacting comprehensive health insurance reform that retains the employerbased system. This report presents selected legal considerations inherent in amending two of the primary federal laws governing employer-sponsored health care: the Employee Retirement Income Security Act (ERISA) and the Internal Revenue Code (IRC)."

ERISAclaim.com - "Overpayment" Refund Request Response & Appeals

 

 

 

 

ERISA & Claim Denials

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"

 

ERISA & Health Claim
What Is ERISA and How Does It Affect Patient Rights?

 

"ERISA was enacted in 1974 to protect the pension and welfare benefits that employers provide their workers. It currently covers about 2.5 million health plans and 125 million workers, retirees, and dependents."

 

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."

 

 

$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 ERISAclaim appeals.  This situation is so popular in health-care community.

 

 

 

 

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."

 

 

   
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