Appeal Book with
$50.00 Discount

Denials + Recoupment = Inflation + Fraud or Cost-Sharing?

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."

USATODAY.com - Hospitals Sock Uninsured with Much Bigger Bills

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

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

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."

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.

"Class Actions" v. "New Strike Force"

Medical Fraud Every Day?

Appeal or Re-Bill After Denial?

You Must APPEAL

No Re-Billing!!!

Claim Appeal or Sentencing Appeal?

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)

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."

New & Interactive From DOL

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

To Avoid "John Q.
ERISA
Enforcement"

The Root of U. S. Healthcare Crisis

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

ERISA Failure, Noncompliance and Nonenforcement of