ERISA Claim Consulting Services

What is ERISA Claim Consulting?

$4,000.00/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

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! 

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.

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."

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."

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.

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.

"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.

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.

This valuable study has pointed out the direction but failed to provide a turnkey practical solution.

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.

Aetna (DOL/ERISA), First Health, 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?

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.

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.

Traditionally health-care providers and facilities have little or no knowledge of ERISA claim procedures when dealing with health-care claim disputes and denials.  They will outsource billing and coding to independent services in hope to recover these claims to reduce denial rates, while most of these claim denials are not in dispute of coding and billing, and independent coding and billing services offer only billing and coding services.  Or they will demand physicians for better clinical documentations in hope to reverse denial decisions while documentations are not in dispute for the denied claims.  Without any luck and success and having tried every efforts through state and national medical associations for organized fighting back campaign with little or no success, most of them automatically turn these denied claims to outside consumer collection agencies to collect from patients, while collection agency generally only collects undisputed debts instead of disputed or denied claims for reimbursement.  Under current recession economy and escalating health cost environment, most of these consumer collection practice resulted little success in collecting money from patients, but more frustrations, and loss of marketing share with negative public relations or possible backfiring from patients with lawsuits for medical malpractice or consumer fraud.

According to latest hospital CEOs survey conducted by American College of Health-care Executives in November 2002, of the 984 hospital CEOs respondents, 65% named reimbursement issues in top three concerns.

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.

For Maximum Reimbursement through ERISA Compliance

For Reimbursement/Financial Crisis Turnaround

To Establish in Your Medical/Healthcare Facility
The Nation's First Departments/Division of
 

ERISA Healthcare Claim Appeals and Reimbursement

Please e-mail for details