The Only Company with Compliant Solutions for All of You

ERISA Seminars for Healthcare Claim Reimbursement and Denial Management are slowly, after 30 years, but surely and finally getting into the mainstream of the healthcare financial industry (pdf, page 2 & page 4), even for Healthcare Financial Management Association, HFMA, in 2005 for its "32,000 members employed by hospitals, integrated delivery systems, long-term and ambulatory care facilities, managed care organizations, medical group practices, public accounting and consulting firms, insurance companies, government agencies and other healthcare organizations."  So, you won't be alone or doing something wrong with ERISA. The question is how you are going to be good or the best at ERISA for denial management ahead of everyone else in the industry, by finding the best and taking the best ERISA seminars! 

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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!

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.

2 Days
14 hours
$1,450

2 Days
14 hours
$1,650

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 © 2001-2005

Medicare Reimbursement

v.

Former Process

Medicare Claims Processing Manual

 Strategies for

Reimbursement Success &

1. Documentation

2. Fraud And Abuse

3. Medical Review

4. National Correct Coding Initiative (NCCI)

5. more

ERISAclaim.com - Supreme Court Managed Care ERISA Watch

1. An Employee's Guide to Health Benefits Under COBRA - The Consolidated Omnibus Budget Reconciliation Act of 1986 [View]

2. Employer Bankruptcy: How Will it Affect Your Employee Benefits?  [View]

3. Filing A Claim For Your Health Or Disability Benefits [View]

4. How to Obtain Employee Benefit Documents from DOL [View]

5. Information Workers Need to Know to Protect their Health Coverage [View]

6. In Brief: Can the Retiree Health Benefits Provided by Your Employer Be Cut? [View]

7. Life Changes Require Health Choices [View]

8. MEWAs: A Guide to Federal and State Regulation  [View]

9. Pension and Health Care Coverage...Q&As for Dislocated Workers  [View]

10. Protecting Pension and Health Care Benefits after Job Loss [View]

11. Protections For Newborns, Adopted Children, And New Parents - The Newborns' and Mothers' Health Protection Act of 1996 [View]

12. Top 10 Ways to Make Your Health Benefits Work for You [View]

13. Work Changes Require Health Choices [View]

14. Your Health Plan And HIPAA...Making The Law Work For You [View]

15. Your Rights After A Mastectomy...Women's Health & Cancer Rights Act of 1998 [View]

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

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

Title 29 U.S.C. § 1141 states:

 

"It shall be unlawful for any person through the use of fraud, force, violence, or threat of the use of force or violence, to restrain, coerce, intimidate, or attempt to restrain, coerce, or intimidate any participant or beneficiary for the purpose of interfering with or preventing the exercise of any right to which he is or may become entitled under the plan, this title, section 3001, or the Welfare and Pension Plans Disclosure Act. Any person who willfully violates this section shall be fined $10,000 or imprisoned for not more than one year, or both. The amount of fine is governed by 18 U.S.C. § 3571. The U.S. Sentencing Guidelines address 29 U.S.C. § 1141 under the guidelines for "Fraud and Deceit" (U.S.S.G. § 2F1.1) or for "Extortion by Force or Threat of Injury or Serious Damage (U.S.S.G. § 2B3.2)......"

 

"For example, Section 1141 would reach the use of deception directed at misleading a welfare plan beneficiary as to the amount of health benefits owed to the beneficiary under the terms of the plan or at misleading a pension plan participant as to the amount of retirement benefits to which he would become entitled under the plan upon his retirement."

Hospital CEO's Confessed Their Biggest Headaches:

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

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

What You Need to Know About Your Employer-Sponsored Coverage

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

Full Report (pdf)

Medical Fraud Every Day?
Appeal or Re-Bill After Denial?
You Must APPEAL
No Re-Billing!!!
Claim Appeal or Sentencing Appeal?
Your Choice
Maximal Reimbursement
through ERISA Appeal &
Fraud Prevention and Compliance

Aetna:  Leading the Fight Against Health Care Fraud [PDF] View as HTML

"Thanks to this highly collaborative relationship, we know how to identify fraud because we know what to look for.

 Medical Fraud

1. Unusual provider billing practices.

2. Discrepancy between the submitted diagnosis and the treatment.

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

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

5. Alterations on claim submissions.

6. Pressure for quick claim payment."

Payments Go Under a Microscope (washingtonpost.com) January 12, 2004

"MAMSI and CareFirst recoup overpayments to doctors by making deductions from future reimbursements. Doctors can appeal insurers' decisions. But, in the end, they usually pay up, doctors and insurers agree."

Employers Audit Workers' Health Claims (Wall Street Journal via SFGate.com) & baltimoresun.com - Health plan 'stings' on rise

Excerpt: "Looking to bring down soaring health-care costs anywhere they can, more employers are scouring their health plans for fraud, abuse and simple mistakes by employees or administrators.

.......The number of requests for such audits jumped 50 percent last year, Mr. Farley estimates."

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

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

Clinton Township Firm Convicted of Overbilling (Macomb Daily)

"The case is somewhat unusual in that a corporation was named as a criminal defendant in the case, but Kaiser said that is not unheard of since corporate law can make a firm liable for criminal wrongdoing, and its principal office holders in return are responsible for any judgments or punishments the courts impose.

David Griem, the defense attorney for Emergency Management who was also named the principal to enter a guilty plea on its behalf, also could not be reached for comment after the sentencing hearing. In court, however, he turned over a check to the Blue Cross insurance company officials in attendance and said the company would pay the $5,000 court costs on time as well."

"Class Actions" v. "New Strike Force"

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

ERISA Failure Syndrome
U.S. Healthcare Crisis Trilogy
(Copyright © 2004 by Jin Zhou,  ERISAclaim.com)

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GAO-04-312
?

Weirton Steel cancels 10,000
GM: $67.5 billion in 2003

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

Healthcare Disaster at Fault Verdict Index:
U.S. Government 30%
U.S. Employers & Insurers 30%
Healthcare Providers 30%
Consumers 10%

Rx-1  $$$$$$$$$ERISA$$$$$$$$$$  Rx-2

To Avoid "John Q. ERISA Enforcement"

Health Benefits Laws By State
(Interactive Tools From Insure.com)

Health Insurance Mandates in the States, 2004: a State-by-State Breakdown ... (PDF)
(Council for Affordable Health Insurance)

Kaiser statehealthfacts.org

Consumer Guides for Health Insurance in Every State and the District of Columbia (Georgetown University)

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

Full Report (pdf)

To Avoid "John Q.
ERISA
Enforcement"

The Office of General Counsel has issued the following informal opinion on January 26, 2000, representing the position of the New York State Insurance Department.

Licensing of ERISA-Covered Benefit Plan Administrator

Conclusion:

"Although the plan may be exempted by the preemptive effect of ERISA from licensure as an insurer under the Insurance Law, the administrator ......"               click for more details

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

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

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

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

Health Spending Projections Through 2013
New Federal Claim Regulation (Final Rule)
Benefit Claims Procedure Regulation (FAQ)
Amendments to Summary Plan Description Regulations (Final Rule)
Patient's Rights Claims Procedure Regulation (Fact Sheet)
U.S. Health-care Crisis & ERISA Criminal Enforcement
CBO's analysis of the President's budgetary proposals for fiscal year 2005
Fact Sheet: Affordable Health Care for America's Families (White House)

Rx-1  $$$$$$$$$ERISA$$$$$$$$$$  Rx-2

Denials + Recoupment = Inflation + Fraud or Cost-Sharing?
Rx = Compliant Denial & Appeals!

Forbes.com: "Roughly one in seven Americans has no health insurance. That hurts HCA Inc. (nyse: HCA - news - people), the largest U.S. hospital chain, which last year wrote off $2.21 billion of revenue because patients couldn't pay their bills."

The American Hospital Association (AHA): "Hospitals today are faced with the challenge of managing their limited resources, while continuing to deliver the highest standard of care. According to health care experts, the cost of clinical denials to individual healthcare organizations averages $3.3 million annually. However, many hospitals do not have the resources or the expertise needed to avoid unpaid days at the end of admissions and lead the denial-appeals processes."

Payments Go Under a Microscope (washingtonpost.com) "MAMSI and CareFirst recoup overpayments to doctors by making deductions from future reimbursements. Doctors can appeal insurers' decisions. But, in the end, they usually pay up, doctors and insurers agree."

Hospital Pricing and the Uninsured, Glenn Melnick, Ph.D., "Price Gouging"
(Subcommittee on Health Hearing on the Uninsured, Tuesday, March 09, 2004)

U.S. FILES COMPLAINT AGAINST NATIONAL ACCOUNTING FIRM UNDER FALSE CLAIMS ACT (DOJ Press Release) "January 5, 2004 - PHILADELPHIA – United States Attorney Patrick L. Meehan announced today the filing of the Government's complaint against national accounting firm Ernst & Young. According to the complaint, nine hospitals paid Ernst & Young for billing advice – advice which later caused the submission of false claims to the Medicare program."

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

Excerpt: "Looking to bring down soaring health-care costs anywhere they can, more employers are scouring their health plans for fraud, abuse and simple mistakes by employees or administrators.

.......The number of requests for such audits jumped 50 percent last year, Mr. Farley estimates."

USATODAY.com - Hospitals Sock Uninsured with Much Bigger Bills

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

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

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

HMO Crisis Is Really An ERISA Crisis!
HMO & PPO Managed Care Contracting to 
Disregard & Substitute ERISA SPD & Claims Procedure
Is The Primary & Inevitable Cause of Medical Inflation
Costly Managed Care & Medical Malpractice Lawsuits
American Job Export!

ERISA Failure Damages Are Greater Than
9/11 and Pearl Harbor Tragedies Combined
U.S. Health-care Crisis & ERISA Criminal Enforcement
 

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

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)

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)

New Federal Claim Regulation (Final Rule)

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

2. "The term `health care professional' means a physician or other health care professional licensed, accredited, or certified to perform specified health services consistent with State law." [page 70271 CFR § 2560.503-1(m)(7)]  

"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.