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Self-Insured
Health Plans Should Have Recovered Millions Of Dollars From Billions
Of Dollars In TPA’s Overpayment Recoupment Practice
- 02-24-2011
ERISAclaim.com Announced 2011 Free
Webinars And Plan Assets Recovery Programs To Assist Self-Insured
Health Plans To Recover Hundreds Of Millions Of Dollars In Plan Assets
From Successful TPA’s Overpayment Recovery In Billions Of Dollars, As
More Than 60% Of TPA Recovered Money Originated From Self-Insured
Plans And Should Be Returned To Self-Insured Health Plans Under New
DOL Contributory Plans Criminal Project.
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New Federal Health Claims & Appeals Laws
&
Regulations
for 193 Million Americans
Effective 09-23-2010
©2010, Jin
Zhou, ERISAclaim.com |
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President
Obama Signing Health Bill on
03/23/2010
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President
Gerald R. Ford Signing ERISA on 09/02/1974 |
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New Webinars,
Seminars & Certification Classes Announced for New Federal Health
Claim Appeals Regulations on July 22, 2010 from HHS, DOL & IRS,
Effective On Sept. 23, 2010 for 193 Million Americans |
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UNITED STATES
DEPARTMENT OF LABOR
(Links to DOL)
©2010, Jin Zhou, ERISAclaim.com |
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Statutory Laws [PDF]
[PDF]
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Employee Retirement Income Security Act — ERISA |
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Webinars,
Seminars & Certification Classes for New Federal Health Claim Appeals
Regulations
ERISAclaim.com
- Free Webinars - New Federal Claims & Appeals Regulations, Effective
Sept. 23, 2010, for 193 Million Americans
ERISAclaim.com: Seminars - 2010 Two-day
Basic ERISA Appeal Seminars - Denials and Overpayment Appeals
ERISAclaim.com - 2010
PPACA & ERISA Claim
Specialist Certification Programs in Chicago, Illinois
ERISAclaim.com: Create An Appeal
Department for Your Hospital or Practice
(In-house, onsite ERISA Claim Specialist Certification Programs)
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Free Webinar Registration for Self-insured Health Plans
Space is limited and only open to self-insured health plans
Webinar Title:
Overpayment Recoupment Embezzlement Recovery
Reserve your free Webinar seat now at
https://www1.gotomeeting.com/register/857663256
Date:
Wednesday, December 23, 2009, Time: 12:30 PM - 1:00 PM CST
https://www1.gotomeeting.com/register/177031920
Date:
Wednesday, January 27, 2010, Time: 12:30 PM - 1:30 PM CST
https://www1.gotomeeting.com/register/514303152
Date: Monday,
February 22, 2010, Time: 12:30 PM - 1:00 PM CST
Free Overpayment Webinar Announced For
Self-insured Health Plans To Get Immediate Relief from New $1 Trillion
Overpayment Recoupment Embezzlement Market 11-23-2009, Hanover Park, IL |
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Embezzlement Recovery Services (ERS)
for Midsized and Large ERISA Health
Plans
“Anti-fraud initiative is not
complete until and unless the recouped overpayment money originated from the
plan assets is finally returned to the original self-insured health plans,
or the fake anti-fraud crusaders are the real fraud culprit”, said Dr. Jin
Zhou, the president of ERISAclaim.com
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Why
ERISAclaim.com &
Overpayment
Recoupment Embezzlement Recovery? |
|
Compliant
Recovery
From Potentially Probable
Embezzlement Of Plan Assets
From An Estimated More Than $1 Trillion
Overpayment Recoupment
Market;
With Our Unique Industry Expertise
And Know-How, To Assist Self-insured ERISA Plans In Most
Complicated And Sophisticated Healthcare Claim Environment Under
ERISA, Through Compliant Claim History And Overpayment Auditing,
Multiple Facet Analysis Of Claims Payment History With
Overpayment Demand, Cross Plan And Across Participant Silent
Overpayment Recoupment,
Plan Assets Disclosure And Reporting Assistance, 5500 Form
Validation, And More...... To Recover As Much As Possible From
Stolen, Mismanaged Or Embezzled Plan Assets;
Our
Embezzlement
Recovery Services (ERS)
From
Overpayment Recoupment
Market Is Completely On Contingency
Basis Without Any Cost To The Plan Sponsors. |
The ERISAclaim.com’s new
Embezzlement Recovery Services (ERS)
was created
in the wake of the
latest launch of Department of Justice (DOL) Financial Fraud Enforcement
Task Force and recent Department Of Labor (DOL) enforcement initiative
to prosecute "embezzlement of plan assets", and the reports of possible new
$1 trillion successful and pending recoupment of the alleged healthcare
overpayment, as reported from industry news and legislative testimony. More
than 55% of employer-sponsored plan participants and beneficiaries are from
self-insured ERISA plans, and the most recouped money for alleged
overpayment or fraud were never returned to self-insured ERISA plans that
originally paid the allegedly overpaid healthcare claims as a part of
$2.5 trillion U.S. health expenditure annually.
As
the
Attorney General Eric Holder said at DOJ Financial Task Force Press
Conference on November 17, 2009, that, "This task force's mission is not
just to hold accountable those who helped bring about the last financial
meltdown, but to prevent another meltdown from happening”.
"It's not enough to prosecute fraud only after it's
become widespread,"
Treasury Secretary Timothy F. Geithner said at the DOJ press conference.
"We can't wait for problems to peak before we respond. We're seeking
comprehensive financial reform to create a more stable, safer financial
system and stepping up our enforcement strategy."
Please contact Dr. Jin Zhou at
ERISAclaim@aol.com or 630-808-7237 for more
details.
"It was a beautiful
Monday morning, you woke up and found your car was stolen, you called your
local police department and luckily, they found your car in one day. After
you thanked them for your car's speedy recovery, the Police Department kept
your car because they found the car for you, unless you call FBI, you never
going to get your car back. You spoke to your high school kid and your
spouse, they both believe finder don't get to keep it. you asked them
which federal and state law said so, both your kid and your spouse replied:
"it's just a common sense".
"In healthcare industry, a lot of things don't seem to
make any common sense anymore". Said, Dr. Jin Zhou, the president of
ERISAclaim.com.
It was well known that there were huge numbers of healthcare overpayment
claims, an estimated more than $1 trillion, for the past 5 to 6 years, and
there were reportedly successful recoveries from providers for
hundreds of millions of dollars of overpaid claims originally paid by the
self-funded ERISA plans in the healthcare industry. In most cases, no one
in the country, plan sponsors, finders or even government, is sure as to who
should finally get to keep the recovered ERISA plan assets, because in
healthcare industry, a lot of things don't seem to make any common sense
anymore.
Federal law,
29 U.S.C. §1106, Prohibited Transactions,
specifically prohibits any TPA from embezzling, converting, or stealing the
plan assets through the recouped overpayment money out of the plan assets in
terms of transferring to, or using by or for
the benefit of a party in interest, of any assets of the plan, or
dealing with the assets of the plan in his own
interest or for his own account.
Federal law,
29 U.S.C. §1104, Fiduciary Duties, requires every plan administrator and
fiduciary to defray reasonable expenses of administering the plan and to
safeguard plan assets diligently with the care, skill and prudence. The
self-insured ERISA plan administrators have statutory and fiduciary duties
to investigate the alleged negligence and fraud in alleged overpayment
inconsistent with plan provisions, and to take immediate actions to recover
from the plan’s TPAs with successful recoupment for the alleged overpayment
from the plan assets. A TPA shall return the unused or recouped plan assets
to the original ERISA plan within six months.
More than 60% of employer-sponsored health plans are self-funded with
combination of the employee payroll deduction and the employer contribution.
The employee healthcare benefits are the second-largest employee expenses
after employee payrolls. The double-digit increase in health insurance
premiums in the past decade has put many companies out of business,
including General Motors, and traumatized many otherwise healthy companies,
partially leading to mass U.S. job outsourcing to other countries and to
U.S. economy recession. U.S. health expenditure has been steadily
skyrocketing to
$2.4 trillion for 2008 and $2.529 for 2009, 16-17% of GDP.
Undetected overpayment in healthcare claims is one of the most significant
reason for double digits premium increase, it was reported that up to 50% of
U.S. health expenditure was due to health care fraud, medical inflation,
unnecessary treatment or waste and self-inflicted excessive administrative
costs as well as very little reported
embezzlement of plan assets.
Complete
recovery of overpaid overpayment claims, originally paid out from ERISA plan assets, and to restore stolen or mismanaged ERISA plan assets to
those self-funded ERISA plans are the most important and most effective ways
to save hundreds of millions of dollars for 60% of the employer-sponsored
health care plans in America.
Unfortunately, most self-funded health plans are powerless and clueless in
how to claim the stolen treasure from the "TPA or ASO" Department in the
past decade because of the complexity of ERISA framework and absolute
monopoly of managed-care environment, or inadvertent conflict of interest in
benefits broker fraud as reported and prosecuted initially in New York and
subsequently nationwide several years ago.
Thanks to President Obama, with forthcoming Obama health care reform and new
DOL 2010 enhancement goals announced on September 14, 2009, new DOL EBSA
boss, Assistant Secretary of Labor Phyllis Borzi laid out a new and vigorous
plan for the Employee Benefits Security Administration (EBSA) that she now
heads. It was clear that enforcement of the law and promises made by Obama
in his campaign will be a driving focus. “The previous Administration
focused on compliance assistance,” she noted, “but that’s only good if it is
combined with strong enforcement”, as an example, Borzi identified
“embezzlement of plan assets” as “the most egregious and persistent
violations” of ERISA that EBSA has initiated a criminal project to
prosecute, as the new
DOL ERISA
regulatory enforcement drastic changes from “The previous Administration
focused on compliance assistance” to the “New Sheriff” prioritized vigorous
and “strong enhancement” to prosecute “embezzlement of plan assets”.
Congress specifically intended in enacting ERISA in 1974 to provide
exclusive authority for withholding and distribution of plan assets in case
of withdrawal liability, overpayment and plan terminations regardless of
contracting with service providers (TPA/ASO) and participation of
managed-care networks.
When an ERISA plan contracted with a TPA/ASO service provider to administer
the ERISA plan claims, regardless of managed care contracting and the network
participation, both plan sponsor or plan administrator and claim
administrator have statutorily imposed fiduciary duties to distribute plan
assets exclusively for providing benefits to the plan participant and
beneficiary. When an ERISA plan terminated service contract with a TPA/ASO,
the assets of welfare plan must be distributed only in accordance with terms
of the plan.
When a TPA/ASO service provider, fiduciary or notn-fiduciary,
discovered recoverable overpayment and successfully recovered the
overpayment as the plan assets, the service provider must follow strict
statutory requirements and the terms of the plan to accurately disclose and
report all recovered overpayments to the plan administrator in accordance
with
29 USC §1103. When a TPA/ASO discovered and recovered overpayment after
the expiration of the TPA/ASO service agreement, "The
assets of a welfare plan which terminates shall be distributed in accordance
with the terms of the plan in accordance with 29 USC §1103. The TPA/ASO
service provider shall be compensated only in accordance with relevant TPA/ASO
Service Agreement with the self-funded ERISA Plan, rather than automatically
convert recovered or recouped plan assets into bonus compensation for
correcting its own mistakes and the negligence in overpayment practice.
Under any circumstances, the assets of the welfare plan, either in form of
contribution or payment, made by the employee payroll deduction or employer
contribution, to a plan by mistake of fact or withdrawal of liability
resulting in overpayment, are always the plan assets governed under ERISA,
29 USC §1103, rather than fraudulently claimed PPO contracting income,
paid by PPO providers to PPO operators, a sophisticated scam of embezzling
ERISA plan assets.
Under no circumstances, the assets of the welfare plan, negligently or
inadvertently erroneously overpaid to the claimants or the providers, in
form of overpayment recoupment, shall be converted illegally into
unauthorized TPA/ASO compensation or bonus and subsequently embezzled as PPO
income or kickback for mitigating its own negligent overpayment practice or
concealment of ERISA plan assets from reporting and disclosing to the
Department Of Labor and Department of Treasury in the plan Annual Returns on
5500 Forms.
"ERISA
Madoff"
Could Be
10 Times
Bigger
with Your
Failure of Imagination
(9/11)
Again
U.S. Health-care Crisis
& ERISA Criminal Enforcement
|
Hearing, Senate Committee on Finance,
3-3-04
View Video
or
Transcript
(PDF)
(KaiserNetwork.org)
[Ann
Combs: "No, the results are not good.
It’s a tragedy."]
"In one settled case, the district court judge had to order the
US Attorney’s office to open a criminal investigation,
investigation based on evidence he saw in a private civil case
where there was evidence of money laundering, fraud, health care
fraud, wire fraud, also sorts of RICO violations, a federal
judge had to order the justice department to investigate. That’s
a big problem."
Mila Kofman, Georgetown University
|
It is extremely popular for third-party service providers to the self-funded
ERISA plans to erroneously overpay healthcare claims out of the plan assets,
then years later to recoup such overpayment plan assets and then convert
such recouped ERISA plan assets into something but the original plan assets
without disclosing and reporting to the plan administrators of those
self-funded ERISA plans. Any unauthorized distribution or withholding of the
plan assets from an welfare plan established under ERISA without expressed
authority from the plan trust in accordance with the plan instrument shall
be challenged, audited, investigated and reported to DOL and DOJ for proper
regulatory enforcement investigation, meanwhile plan administrators or plan
fiduciaries must take immediate actions to safeguard ERISA plan assets by
recouping the plan assets from the estimated $1 trillion in overpayment
recoupment market. On September
14, 2009, new DOL EBSA
boss, Assistant Secretary of Labor Phyllis Borzi identified
“embezzlement of plan assets” as “the most egregious and persistent
violations” of ERISA that EBSA has initiated a criminal project to
prosecute.
With unique knowledge of industry known facts, ERISAclaim.com has
launched the nation's first unique
embezzlement
recovery service to
help midsized and large ERISA plans to recover millions of dollars on
a complete contingency basis, to recoup as much as possible from the
recoverable but overpaid healthcare dollars to the original payers and
owners who initially paid out overpaid claims by TPAs and ASOs and are
now entitled to the ownership for and the possession to an estimated
billions of dollars in the $6 trillion dollar healthcare denial
management market.
We will utilize our unique industry expertise and know-how to assist
self-funded ERISA plans in most complicated and sophisticated healthcare
claim environment under ERISA, through compliant claim history and
overpayment
recovery auditing, multiple facet analysis of claims payment
history with overpayment demand, cross plan and across participant silent
overpayment recoupment, plan assets disclosure and reporting assistance,
5500 Form validation, and more...... to recover as much as possible stolen
or mismanaged plan assets from an estimated more than $1 trillion
overpayment recoupment market and $6 trillion health care denial management
market, including all of denied the claims either legitimately or
wrongly for the past 5 to 6 years.
Knowledge is power, ERISA knowledge is superpower in healthcare industry,
saving or breaking employer-sponsored health care system in America.
Our
Embezzlement
Recovery Services (ERS) for self-funded ERISA plans are
completely on contingency basis without any cost to the plan sponsors, and
we are dedicated to compliant assistance through sophisticated and accurate
application of ERISA regulation and diligent fact-finding as well as
diplomatic communications in our
embezzlement
recovery services.
Please contact Dr. Jin Zhou at
ERISAclaim@aol.com or
630-808-7237 for more details.
Related Links on
ERISAclaim.com:
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
ERISAclaim.com - Rx for GM $5.6 Billion
Health-care Crisis with 50% Savings
ERISAClaim.com - Overpayment & SIU in
2009, $1 Trillion Healthcare Bailout & Foreclosures
ERISAclaim.com - The Death of Managed
Care & Health Insurance Industry UCR Fraud
ERISAclaim.com - U.S. "Healthcare $1
Trillion Crisis", You Are The Bailout Plan
ERISAclaim.com - U.S.
Health-care Crisis & ERISA Criminal Enforcement
ERISAclaim.com:
"Failure of Imagination" Again? U.S. Health-Care Disaster
ERISAclaim.com: DOL
Final Rules - The Rule of the Game for 80% of Healthcare Claims in the
U.S.
ERISAclaim.com: DOL
New Guidance - The Rule of the Game for 80% of Healthcare Claims in
the U.S.
ERISAclaim.com -
Supreme Court Managed Care ERISA Watch
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ERISAclaim.com Press
Release
ERISAclaim.com Press
Release
FOR
IMMEDIATE RELEASE:
Free Overpayment Webinar Announced For
Self-insured Health Plans To Get Immediate Relief from New $1 Trillion
Overpayment Recoupment Embezzlement Market 11-23-2009, Hanover Park, IL
“Anti-Fraud
Initiative Is Not Complete Until And Unless The Recouped Overpayment
Money
Originated From The
Plan Assets Is Finally Returned To The Original Self-Insured Health
Plans, Or The Fake Anti-Fraud Crusaders Are The Real Fraud Culprit”,
Said Dr. Jin Zhou.
New Healthcare
Overpayment Recoupment Embezzlement Recovery Service Announced In Wake
Of Launch of New Federal Task Force To Combat Healthcare Fraud Crisis 11-19-2009, Hanover Park, IL
Will Obama's New Financial Fraud Task
Force Catch The New "Trillion-Dollar Madoff" In The Widespread $1
Trillion Healthcare Overpayment Recoupment Embezzlement Crime?
ERISAclaim.com
Announced The Nation's First Embezzlement Recovery Services for Large
ERISA Health Plans from the $6 Trillion Healthcare Denial Management
Market 10-23-2009, Hanover Park, IL
"ERISAclaim.com has gained its unique industry in-depth knowledge and
expertise from working with every segment of health care industry in
more than 10 years. With unique knowledge of the industry known facts,
ERISAclaim.com is dedicated to helping large ERISA plans to recover
millions of dollars on a complete contingency basis."
Related Press Release links:
ERISAclaim.com Announced Free ERISA Webinar for Healthcare Overpayment
Dispute and Claim Denials in Response to Increasing High Demand from
the $6 Trillion Healthcare Denial Management Market
10-19-2009, Hanover Park, IL
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
ERISAclaim.com
Announced 2010 ERISA Seminars for Healthcare Overpayment and Claim
Denial Appeals for the $6 Trillion Healthcare Denial Management
Market.
10-14-2009, Hanover Park, IL
ERISAclaim.com
Announced the Nation's First Certification Program for the ERISA
Claim Appeal Specialist for Healthcare Providers and Managed-Care
Payers,
10-13-2009, Hanover Park, IL
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Industry Overpayment News:
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 employer based 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)."
Contact: John
MacDonald, EBRI, (202) 775-6349,
macdonald@ebri.org
FFE #84, May 28, 2008
73 million Americans Are in
Self-Insured Health Plans
“WASHINGTON—How many Americans are
covered by their employers’ self-insured health plans? Is
there typically a difference in insurance type by firm size?
The February 2008 EBRI Issue
Brief estimates that in 2007 some 73 million American
workers and their dependants were covered by a self-insured
health plan—that is, one in which the employer assumes the
financial risk for providing health care benefits to its
employees, rather than buying insurance .
Some 45 percent of the ERISA
population was in a fully insured plan in 2007, or roughly 60
million people.”
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Blue Cross and Blue Shield Companies'
Anti-Fraud Efforts Collect More Than Half a Billion Dollars in
2009... -- WASHINGTON, May 26 /PRNewswire
"Anti-fraud savings and recoveries increase 47 percent over 2008
"WASHINGTON, May 26 /PRNewswire-USNewswire/
-- Blue Cross and Blue Shield companies' anti-fraud investigations
resulted in overall savings and recoveries of more than $510 million
in 2009, according to data released today by the Blue Cross and Blue
Shield Association (BCBSA). This represents a significant increase
compared to 2008, and contributed to a three-year average return of
$7 dollars for every $1 dollar spent on anti-fraud efforts."
Blue Cross Blue Shield of Michigan
Anti-Fraud Efforts Recoup and Save More Than $277 Million Since
Inception -- DETROIT, May 26 /PRNewswire/ --
"DETROIT, May 26 /PRNewswire/ -- Blue
Cross Blue Shield of Michigan's health care fraud investigation
unit, the oldest and most successful health plan operation of its
kind in the U.S., saved or recovered nearly $277 million since it
first began operation nearly 30 years ago, including $15 million in
savings in 2009."
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."
Independence Blue
Cross Recognized for Anti-Fraud Achievemens
Blue Cross And Blue
Shield Companies' Anti-Fraud Units Recover And Save More Than $249
Million In 2007
Slide 8 - Cost of
Healthcare Fraud
Slide 12 - Cost of
Healthcare Fraud
Anti-Fraud
Initiatives
"Description: Healthcare fraud is NOT
a victimless crime. It increases healthcare costs for everyone. It
is as dangerous as identity theft. Fraud has left many thousands
of people injured. Participation in healthcare fraud is a crime."
Blue Cross And Blue
Shield Companies Receive BlueWorks Awards And Recognition By
Harvard Medical School Researchers For Anti-Fraud Efforts
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Testimony on Health Insurance Fraud
and Retroactive Denial of Reimbursements
Presented to
HOUSE INSURANCE COMMITTEE
Public Hearing
June 10,2009
"Over the
last five years,
my department -the Corporate and Financial Investigations
Department - has recovered more than
$192.5 million
in overpaid claims, and has targeted and is pursuing an
additional $64.8
million for recovery. Although a significant number,
the $192.5 million we have recovered represents only four
tenths of one per cent of all claims we paid over this same
five-year period. Applying the national estimate, that health
care fraud represents 3 percent of the amount spent on health
care every year; my department
should have recovered
$1.4 billion.
Although our recovery of $192.5 million is significant, health
care fraud, waste, and abuse continues to be a problem in
Pennsylvania and we need the help of the State Legislature to
work with us and other insurers to protect the citizens of
Pennsylvania."
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Amednews: Pennsylvania Blues plan
ordered to back off from clawbacks :: Sept. 11, 2009 ...
American Medical News
By
Emily Berry,
amednews staff.
Posted
Sept. 11, 2009.
"A mediator ruled Aug. 13 that the
Philadelphia-based plan
could
not collect for overpayments made more than 18 months earlier
because doing so would violate a class-action settlement over
payment issues between physicians and the BlueCross BlueShield
Assn., reached in 2007 and
finalized in June this
year.....
Independence earlier this year sent letters
to physicians at 1,483
practices notifying them that the plan intended to
collect overpayments made for surgical services,
some of which were in
excess of
$100,000,
said Dennis Olmstead, chief economist and vice president for
practice economics and payer relations for the Pennsylvania
Medical Society."
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.
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."
Recoup d'etat: Fighting recoupment efforts
By Bob Cook,
amednews staff. June 20, 2005.
"Doctors are
complaining that health plans are becoming more aggressive about
demanding refunds after claiming that they've overpaid. Experts
say physicians can become more aggressive about fighting back.
Physician fights
over recoupments are getting more public. For example, in August,
a lawsuit is scheduled to go to trial involving
$15
million in
recoupments Horizon Blue Cross Blue Shield of New Jersey is
seeking from cardiologists in that state. The lawsuit was filed by
the New Jersey chapter of the American College of Cardiology and
the Medical Society of New Jersey."
New Jersey doctors sue insurer over forced payback
By Robert Kazel, amednews staff. Jan.
3/10, 2005.
Analysts say health plans are getting more aggressive in demanding
repayments from physicians.
"That mistrust was
shared by many cardiologists across New Jersey who received
similar overpayment notices at about the same time. In all,
Horizon notified about 600 cardiologists in 273 practices that
they collectively owed
$15 million in connection with
flawed calculation of fees for catheterizations. If repayment was
not made within weeks, Horizon told some groups, it would recoup
the contested funds against future reimbursements."
|
Doctor claims Blue Cross withheld payments
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.
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."
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ERISA &
Claim Denials
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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" |
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ERISA &
Health Claim |
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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." |
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$10,600 ERISA Claim
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| Recent Federal Court Ruling in a Case with
$10,600 medical claim, insurance Co. refused to pay, provider
made numerous demand for payment in almost one year, but no
appeals filed, the court dismissed the lawsuit because provider
failed to exhaust administrative remedy, as required under ERISA,
by filing ERISAclaim appeals. This situation is so popular
in health-care community.
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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.
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Federal and state mandates and the patient’s
benefit document take precedence over these policies.
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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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BCBSIL Adopts New Overpayment Recovery Program
Blue Review Sept. 2004 (page 5 of 8)
"To address
this issue we are introducing a new recoupment process for
refunding overpayments made to contracting providers
for the PPO, BlueChoice and BlueChoice Select products. This
procedure will apply to all claim overpayments requested
after October 1, 2004.....
If we do not hear from you by
telephone or in writing, or you do not return the amount of the
overpayment within 30 days from the date of the follow up
letter, BCBSIL will recover the overpayment by offsetting
current claims payments by the amount due to us." |
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"A healthcare insurer can recover an
amount, wrongly paid to a provider. ... the retroactive denial
of reimbursement results from COB, ... |
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Codified in Title 29 of the
Code of Federal Regulations:
Regulations
Selected links:
2520.102-3 Contents of summary plan description.
2560.503-1 Claims procedure. |
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