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Please e-mail for more details
or
Call: (630) 736-2974
Due to the
recent overwhelming institutional inquiries on our certification programs,
and in order to save or minimize your employee long-distance travel expenses
and associated risks, we are happy to announce that we now offer on-site
educational programs at your location for our ERISA and Medicare seminar and
certification educational programs as well as on-site individual consulting
and executive brainstorming in crisis turnaround.
You may order any individual or
combination of our standard programs for seminar and certification as well
as consulting on both ERISA and Medicare, or with individual customization
of any of our services for your individual needs at closed-door sessions at
significant discounts.
All on-site educational programs can
be ordered with additional executive brainstorming, crisis turnaround
consulting for your institution ranging from executives, managers and
billing and coding staffs, in order to bring everyone in your facility onto
same page: maximum reimbursement through compliance of the most significant
federal laws, ERISA and Medicare.
Basic fee schedules and discounts
are as followings, however each individual arrangement are negotiated with
specific discounts based on individual needs.
We are the first in the nation to
offer this type of comprehensive ERISA and Medicare appeal compliance and
reimbursement programs.
|
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.....
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Price Ranges for
On-site Programs
|
Price
|
Seminars |
Certifications |
Consulting |
| <
20 people |
$4,000 Speaker/per day |
30% discount |
Negotiable |
|
20-40 people |
$5,000/per day |
40% discount |
Negotiable |
|
40-60 people |
$6,000/per day |
50% discount |
Negotiable |
|
60-100 people |
$8,000/per day |
50% discount |
Negotiable |
|
>100 people |
$10,000/per day |
Negotiable |
Negotiable |
All
arrangement have additional speaker expenses paid by your
institution, this is a general quote, each arrangement is negotiated
at different final price for different needs. Please e-mail and call
for specifics.
For specific contents and the prices of each program, please check
our individual web page of the program.
Disclaimer
Please e-mail for more details
|
ERISAclaim.com: Effective as of
02-21-2005
|
Certification Programs |
|
Modules |
Seminar Topics |
|
I 2 Days
14 hours
$1,450
($1,700
with CD-Book & Appeal System) |
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
$1,450
|
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
$1,450
|
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
$1,650
|
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
|
|
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 |
|
Medicare
Reimbursement
New Compliance &
Challenges |
|
New Medicare Appeal
Process & Mandates v.
Former Process
Medicare Claims Processing Manual
Chapter 29 - Appeals of Claims Decisions
CMS Transmittal -
R146OTN
|
New Medicare Appeal
Strategies for
Reimbursement
Success &
-
Documentation
-
Fraud And Abuse
-
Medical Review
-
National Correct Coding Initiative
(NCCI)
-
more
|
New
Medicare Appeal Laws
Intertwined
with ($183 million/y)
ERISA Claims Laws |
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
$$$$$$$$$ERISA$$$$$$$$$$
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."
|
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Now You see, Now You
Don't?
Never "Don't" for a
Moment!!!
Excerpt: "Blue Cross and Blue Shield plans
often have the largest provider networks of any insurer in
their service area. In several markets, however, Blues plans
are in the midst of contract disputes with health care
providers over payment rates. These conflicts threaten to
shrink some Blues' networks, while others already have seen
providers leave the network."
"Even at companies where they're not a
problem -- yet -- directors need to know the treatment
options."
Excerpt: "In
the pressure cooker known as our national healthcare
system, all the major players seem ready for battle. On the
right, advancing slowly ..., are the cost-cutting forces of
managed care. On the left, hurling brickbats at almost
everyone, are the physicians. In the rear, licking their
wounds after their latest brawl with the physicians, and
plotting their next ambush on the health plans, are the
hospitals. Looking on from the sidelines are the healthcare
policy-makers, employers and random pundits-their theories
often two steps behind
the facts on the ground."
|
|
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
|
|
"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
-
Unusual provider billing practices.
Discrepancy between the submitted diagnosis and the treatment.
Diagnoses or treatments that are outside the practitioner’s
scope of practice.
Claims that are resubmitted
with coding changes to gain benefits.
Alterations on claim
submissions.
Pressure for quick claim payment."
Payments Go Under a Microscope (washingtonpost.com)
January 12, 2004
"MAMSI and CareFirst
recoup overpayments to doctors by making
deductions from future reimbursements.
Doctors can appeal insurers' decisions.
But, in the end, they usually pay up, doctors and insurers
agree."
Employers Audit Workers' Health Claims
(Wall Street Journal via SFGate.com) &
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."
|
Health Care Fraud Report Fiscal Year 1998
|
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. ...."
|
ERISAclaim.com - A $1.0 Trillion Nuclear Solution to U.S. Health-care
Crisis & $44 Trillion Budget Deficits
ERISAclaim.com: 50% Savings - Healthcare Crisis Turnaround for
Employers, Insurers & TPA's
"Zhou's Model of Prudent Health Care"
Are All
Consultants Corrupt? (Fast Company)
|
Denials +
Recoupment =
Inflation +
Fraud or
Cost-Sharing?
Rx =
Compliant Denial & Appeals!
|
|
Forbes.com: "Roughly one in seven Americans has
no health insurance. That hurts HCA Inc. (nyse:
HCA -
news
-
people), the largest U.S. hospital chain, which
last year wrote off $2.21 billion
of revenue because patients couldn't pay their
bills."
The American Hospital Association (AHA): "Hospitals today are faced with the challenge of managing their
limited resources, while continuing to deliver the highest standard of care.
According to health care experts, the cost of clinical
denials to individual healthcare organizations averages
$3.3 million
annually. However, many hospitals do not have the resources or the
expertise needed to avoid unpaid days at the end of admissions and lead the
denial-appeals processes."
Payments Go Under a Microscope (washingtonpost.com)
"MAMSI and CareFirst recoup overpayments to doctors by making
deductions from future reimbursements.
Doctors can appeal insurers' decisions.
But, in the end, they usually pay up, doctors and insurers agree."
Hospital Pricing and the Uninsured,
Glenn Melnick, Ph.D.,
"Price
Gouging"
(Subcommittee on Health
Hearing on the Uninsured,
U.S.
FILES COMPLAINT AGAINST NATIONAL ACCOUNTING FIRM UNDER FALSE CLAIMS ACT
(DOJ
Press Release) "January 5, 2004
- PHILADELPHIA –
United States Attorney Patrick L. Meehan announced today the filing of the
Government's
complaint against national accounting firm Ernst & Young.
According to the complaint, nine hospitals paid Ernst & Young for billing
advice – advice which later caused the submission of false claims to the
Medicare program."
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
|
Breaking News
950,000 MD's Settled With Aetna & Cigna on ERISA
"Aetna
and CIGNA Settlement Secrets"
"Talking
Points"
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."
"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)
-
"Plans must
consult with
appropriate health care
professionals in
deciding appealed claims
involving medical judgment."
[70268-70269,
CFR § 2560.503-1(h)(3)(iii)]
-
"The term `health care professional' means a
physician or other health care professional
licensed, accredited,
or certified to perform specified health
services
consistent with State law." [page
70271
CFR § 2560.503-1(m)(7)]
 |
"medical doctors in Texas"
=
MD licensed to practice medicine in Texas
for a Texas ERISA case;
|
|
"a medical professional in the
relevant area" = relevant area of state laws in license
jurisdiction, scope of practice and relevant local standard of care;
|
|
"licensed"
= licensed by the State Government/licensing board;
|
|
"to
perform"
= to practice medicine or health care services in the
State;
|
|
"specified
health services"
= medical procedures or services being reviewed or denied, instead of
file review or insurance coverage reviews
services;
|
|
"consistent with State law"
= consistent with State laws where the health care professional is
legally licensed to practice medicine or health care services with
respect to state jurisdictions, scope of license and state local
medical standard of care.
|
"The term `health care professional' means, in layman term, a
physician or other health care professional who is at least licensed in
your state (and more, board certified too) to practice the
specified/specific health services being reviewed or denied of your
claims, consistent with your state law jurisdiction, scope of practice
and local medical standard of care. Someone who is not licensed to
practice the same health care services specified/denied in your claims
is not qualified as an "appropriate health care
professionals" as defined under ERISA
§ 2560.503-1(m)(7).
Someone who is not licensed in your state to
practice "specified health services" but who is merely registered under
state or other means (URAC, IME, SSD or Peer Reviews) to do Utilization
Reviews (UR)
is not qualified as an "appropriate health care
professionals" as defined under ERISA
§ 2560.503-1(m)(7).
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.
|
|
Why ERISA
Certification Programs for Health-care Providers???
950,000 MD's Settled
With Aetna & Cigna on ERISA
|
-
Health-care claim denial problems have fundamentally threatened
health-care providers business survival;
-
Up to
1/3 health-care claims was completely denied, rest of them partially
and significantly denied. Up to
600 billion were denied health-care claims in 2001.
-
$1.55
trillion were spent in national health-care in 2002, 14.9% of GDP,
out of which $207.2 billion were out-of-pocket payments, rest of them
are health-care claims through third party reimbursement claims.
-
ERISA
regulates about 80% of health-care claims and is never understood by
health-care providers;
-
Traditional Assignment of Benefits Form used in hospitals and
physician's offices does not provide any rights for physicians to
dispute with insurance companies over claim denials except for only
receiving undisputed and paid claims,
according to new government guidance
for new claims procedure, Q-B2;
-
New Federal Claim Procedure, to be
effective January 2002, has provided health-care providers with
best and maximal protections against improper denials of medical
necessity, usual customary and reasonable, policy exclusion, PPO
discount and pre-existing conditions, Q-C16, Q-C17, Q-D9 & Q-D10;
-
Only with proper understanding of what constitutes a sufficient
designation of authorized representative, as required by
new
regulation, to ensure you to obtain
ERISA rights
guaranteed by federal law and to enjoy
maximal protection
to protect your business survival and prosperity.
-
In
a letter
from Republican Congressional leader, John Boehner,
to the
Secretary of Labor and insurance/benefits industry,
he states that "specifically,
we are concerned about provisions in the final rule that go even
further than the patients' rights bills
passed by
the Congress", and he urged DOL to revise and
delay the entire claims regulation.
|
Please e-mail for details
|
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
-
Unusual provider
billing practices.
Discrepancy between
the submitted diagnosis and the treatment.
Diagnoses or
treatments that are outside the practitioner’s scope of
practice.
Claims that are
resubmitted with coding changes to gain benefits.
Alterations on claim
submissions.
Pressure for quick
claim payment."
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)
|
|
