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What is ERISA Claim Consulting?
$2,000.00--3,000.00/day & 2 Days
Minimum
Problem Focused Solutions With
ERISA Claims
We/You Identify Your Specific,
Worst, Urgent Problem(s)
in Your Practice/ Facility
AND
Stop & Prevent Claims Denials &
Delays
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ERISAclaim.com: Unique Services for
Your
Specific Problem Focused Solutions |
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Denials +
Recoupment =
Inflation +
Fraud or
Cost-Sharing?
Rx =
Compliant Denial & Appeals! |
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Health Care Analysts See Bleak Outlook for Hospitals with Reimbursement
Changes (The New York Times; one-time registration required)
Excerpt: "Chill is in the air for
hospitals accustomed to having insurers - both public programs like Medicare
and private health plans - pay ever higher prices for hospital services.
That era appears to be ending, some analysts say."
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
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Breaking News
950,000 MD's Settled With Aetna & Cigna on ERISA
"Aetna
and CIGNA Settlement Secrets"
"Talking
Points"
What You
Should Know about Filing
Your Health Benefits Claim
(DOL Claims Card)
U.S. Health-care Crisis & ERISA Criminal Enforcement
Maximal Reimbursement
or Crisis Turnaround to Get
Paid!
ERISAclaim.com concentrates entirely on an
unique and
unprecedented
approach to denial and
appeals for health-care ERISA claims. Although ERISA has been in existence
for 28 years and regulates about 80% of health-care claims in U.S.,
it was
never understood by health-care providers, physicians and hospitals.
We provided consulting service to individual health-care
providers, clinics and hospitals on specific needs of health-care ERISA
claim denials and appeals by educating,
analyzing and
fundamentally
reengineering your claim appeal process for more effective reimbursement
consistent with current
federal statutes and regulations when
traditional
and conventional insurance appeal strategy and practice failed.
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"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 |
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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)
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."
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."
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Health Care Fraud Report
Fiscal Year 1998
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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" |
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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".
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