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Hearing, Senate Committee on Finance
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US Supreme Court Visits ERISAclaim.com
at 11:57:03 AM on Friday, November 21, 2003

 

New Federal Health Claims & Appeals Laws & Regulations

for 193 Million Americans

Effective 09-23-2010

©2010, Jin Zhou, ERISAclaim.com

Photo of President Gerald R. Ford signing Employee Retirement Income Security Act of 1974

President Obama Signing Health Bill on 03/23/2010

President Gerald R. Ford Signing ERISA on 09/02/1974

New Webinars, Seminars & Certification Classes Announced for New Federal Health Claim Appeals Regulations on July 22, 2010 from HHS, DOL & IRS, Effective On Sept. 23, 2010 for 193 Million Americans

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Patient Protection and Affordable Care Act

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Employee Retirement Income Security Act — ERISA

Webinars, Seminars & Certification Classes for New Federal Health Claim Appeals Regulations

 

ERISAclaim.com - Free Webinars - New Federal Claims & Appeals Regulations, Effective Sept. 23, 2010, for 193 Million Americans

 

ERISAclaim.com: Seminars - 2010 Two-day Basic ERISA Appeal Seminars - Denials and Overpayment Appeals

 

ERISAclaim.com - 2010 PPACA & ERISA Claim Specialist Certification Programs in Chicago, Illinois

 

ERISAclaim.com:  Create An Appeal Department for Your Hospital or Practice (In-house, onsite ERISA Claim Specialist Certification Programs)

 

Unanimous US Supreme Court Ruling

In US Health Care Crisis

by Jin Zhou, 02/11/2005

© 2005, Jin Zhou, ERISAclaim.com


Managed-Care Nightmares?

Health-Care Crisis without True Solutions?

 

What Does an Unanimous US Supreme Court Say?

 

On June 21, 2004, an unanimous US Supreme Court ruled that claim processing 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.

 

How Can Anyone in USA, from Congress to General Motor to the White House, from Industry Experts to Patient Advocates, Solve US Health Care Crisis without Even Thinking of ERISA?


"Failure of Imagination" As a Nation Is the Real Tragedy

 

ERISAclaim.com - Supreme Court Managed Care ERISA Watch

 

Unanimous US Supreme Court Ruling In US Health Care Crisis

 

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."

 

 

ERISAclaim.com

Happy
Birthday Sept. 2,
1974
30th
Birthday

 

Happy or Sad 30th Birthday To ERISA?

(Copyright © 2004 by Jin Zhou,  ERISAclaim.com)

Sept. 2, 2004

On Sept. 2, 1974, exactly 30 years ago today, ERISA, The Employee Retirement Income Security Act, was signed into law by President Gerald R. Ford. The congressional intent in enacting ERISA was to protect employees in pension and welfare plans, to provide uniform federal protections in response to the failure of the Studebaker Co. in December 1963, with thousands of long-service employees cheated out off their promised pensions, and to preempt any state laws when the employees pension and welfare benefits were threatened. 30 years later, ERISA Failure in its compliance and enforcement left thousands of retirees without medical benefits, and resulted in a skyrocketing national healthcare expenditure explosion with 45 million uninsured and a possible national pension bailout.

ERISA Failure Syndrome

U.S. Healthcare Crisis Trilogy

 

Jin Zhou Identifies "ERISA Failure" That Killed U.S. Healthcare

"Failure of Imagination" Again?

 

 

ERISA Celebrates 30th Anniversary As Trouble Brews For the Pension Insurance Program (Spencer Benefits Reports)

Excerpt: "The seed for ERISA was planted with the failure of the Studebaker Company in December 1963, leaving thousands of long-service employees without their promised pensions."

 

 

 

ERISA Failure Syndrome

U.S. Healthcare Crisis Trilogy

(Copyright © 2004 by Jin Zhou,  ERISAclaim.com)

 

ERISA
Medical Killing
ERISA
Medical Inflation
ERISA
Insurance Robbery
"Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance

Read Making a Killing

?

 

?

Bar graph showing trends in hospital charges and revenues in California from 1995-2002

?

 

?

GAO-04-312

?


?

American Job ExportING!

Mass layoffs up in January 2004

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%

(ERISA Failure + Managed-Care) Destroyed US Healthcare
(ERISA Failure + Managed-Care + HSA) Invite US Federal Budget Deficit & Social Security Disasters = 100X 9/11 Attacks

 

GAO: Current and Emerging Fiscal and Retirement Security Challenges, American Benefits Council/MetLife Conference, Washington, DC, on January 14, 2005

  1. Rising Health care Costs Have Many Implications (Direct)

  2. Rising Healthcare Costs Have Many Implications (Indirect)

 

Rx-1  $$$$$$$$$ERISA"Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance
$$$$$$$$$$  Rx-2

 

Health costs a big part of GDP (Newsday.com) February 9, 2005

 

"Socolar and Sager co-direct Boston University's Health Reform Program, which attempts to develop solutions to the nation's health care problems. In the report released today, they argue that if health care costs had grown no faster than GDP, the nation would have saved a stunning $1 trillion."

 

Rx-1  $$$$$$$$

"LONG LIVE HMO"

$$$$$$$$$  Rx-2

 

Life and Health Insurers' Earn $26 Billion in First Nine Months of 2004, According to Weiss Ratings (Business Wire (press release), CA - Mar 15, 2005)

 

Weiss Ratings: HMO & Health Insurance News Releases

Release Date
2/7/2005     Higher Co-Pays for Drugs and Doctors Cited as
Most Significant Change to Health Insurance Coverage
2/7/2005     50% of HMOs Financially Strong as Profitability Continues
12/8/2004     HMO Profits Increase 33% in First Quarter 2004
8/30/2004     HMOs Earn $10.2 Billion in 2003, Nearly Doubling Profits
5/3/2004     HMO Profits Skyrocket to $6.7 Billion in First Nine Months of 2003
3/2/2004     HMO Profits Surge 73% in Second Quarter 2003
1/20/2004     HMO Profits Jump 60% in First Quarter 2003

 

  1. GM Credit Rating Cut Again (TheCarConnection.com)

    "In addition, health-care costs in the United States continue to increase at an excessive rate and are a growing burden on GM's financial results. "These continuing large increases in healthcare costs put GM, and many other U.S. businesses, at a significant disadvantage," said Wagoner."

  2. GM's Spinning Wheels (Motley Fool)

  3. Ford Posts Profit on Credit, Autos Lose (reuters.com)
  4. Ford makes more from selling loans than making cars (telegraph.co.uk)

 

U.S. Labor Secretary Elaine L. Chao Announces Stronger Retirement, Health Benefit Security for American Workers - 121% Increase in Monetary Results Shows “Commitment to Protect Hard-Earned Benefits” Release Date: 10/21/2004

"EBSA closed 4,399 civil investigations in FY 2004. Nearly 70% of those investigations resulted in correction of violations under the Employee Retirement Income Security Act (ERISA). Criminal investigations led to the indictment of 121 individuals. In addition, EBSA received a record 474 applications to participate in its compliance assistance program to help employers and plan officials to voluntarily correct specific violations of the law."

EBSA Achieves Record $3.1 Billion in Fiscal Year 2004 Results Press Release

 

 

INVESTIGATION REVEALS WIDESPREAD CORRUPTION IN INSURANCE INDUSTRY

Press Releases

 
Department of Law
120 Broadway
New York, NY 10271
Department of Law
The State Capitol
Albany, NY 12224
 
 
For More Information:
(212) 416-8060
For Immediate Release 
October 14, 2004

Leading Brokerage Firm Sued for Fraud and Antitrust Violations; Insurance Company Executives Plead Guilty; Major Insurance Firms Implicated

"Attorney General Eliot Spitzer today sued the nation's leading insurance brokerage firm, alleging that it steered unsuspecting clients to insurers with whom it had lucrative payoff agreements, and that the firm solicited rigged bids for insurance contracts."

 

Attachments:

 

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

Rx-1  $$$$$$$$$ERISA"Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance
$$$$$$$$$$  Rx-2

Are All Consultants Corrupt? (Fast Company)

 

ASO+HMO+PPO-SPD=$1.8 Trillion/Y US Healthcare Crisis

 

ERISA+SPD-HMO-PPO-ASO=50% Savings

 

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

 

(ERISA Failure + Managed-Care) Destroyed US Healthcare
(ERISA Failure + Managed-Care + HSA) Invite US Federal Budget Deficit & Social Security Disasters = 100X 9/11 Attacks

AHP +HSA + Managed Care =

Winning Battle, But Losing War on Medical Inflation

 

 

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".


"This Is Not Some Wild Theory"

"Cut 50 percent of the cost of health care"

US companies mad as hell at HMO premiums
Are All Consultants Corrupt? (Fast Company)

Evolving Role of Third Party Administrators Brings
New Demands and Innovations
(Employee Benefit News)

 

 

 

Why "Zhou's Model of Prudent Health Care"???

 

National labor and economical security are being harmed every day by our healthcare crisis when we all have been fantasizing practical solutions from political Hollywood and self-destructive Disneyland. Now it's time to do some reality check:

U.S. Firms Losing Health Care Battle, GM Chairman Says (The Washington Post; one-time registration required)

Excerpt: "American manufacturers are losing their ability to compete in the global marketplace in large measure because of the crushing burden of health care costs, General Motors Corp. chairman and chief executive G. Richard Wagoner Jr. said yesterday as he called on corporate and government leaders to find 'some serious medicine' for the nation's ailing health system. In a speech at the Economic Club of Chicago, the auto executive, who is responsible for providing health insurance for ...."

Health costs a big part of GDP (Newsday.com) February 9, 2005

"Socolar and Sager co-direct Boston University's Health Reform Program, which attempts to develop solutions to the nation's health care problems. In the report released today, they argue that if health care costs had grown no faster than GDP, the nation would have saved a stunning $1 trillion."

Excessive Medical Expenses Study Finds that Half of Health Care Dollars Are Wasted (San Francisco Chronicle)

Excerpt: "About 50 percent of health care spending is eaten up by waste, excessive prices and fraud, according to a report set for release [February 9, 2005] by Boston University researchers. Major sources of unnecessary spending include administrative costs and profit in the insurance industry, high prices of prescription drugs and health services and, to a smaller extent, theft and fraud, according to the study."

No Cure Seen for Growth in Employers' Health Costs (12/02/2004, The New York Times; one-time registration required)

Excerpt: "The growth in health care spending by private employers slowed in recent years, creating some optimism that the employers had turned the corner in their struggle with rising costs. But any relief appears to have been short lived, according to a study to be released today. Growth in spending in the first half of 2004 was about the same as it was in 2003, according to the Center for Studying Health System Change, a nonprofit research group in Washington that tracks spending levels."

Tracking Health Care Costs: Spending Growth Slowdown Stalls in First Half of 2004 (Center for Studying Health System Change)

Report (PDF) (Employee Benefit Research Institute)

Excerpt: "The recent slowdown in health care spending growth stalled in the first half of 2004 as health care costs per privately insured American increased 7.5 percent--virtually the same rate of increase as in 2003. Private-sector spending on health care constitutes more than one-half of all health care spending, and both the private and public sectors are subject to similar cost pressures.1 Growth in spending on hospital inpatient care slowed to 5.1 percent in the first half of 2004, ...."

Health Premiums Are Rising As You Read This According to Council of Insurance Agents & Brokers (The Adviser via BenefitNews.com)

Excerpt: "A broker group has found that health insurance premiums are rising by double-digit percentages even over the course of the plan year. In a recently released study (http://www.ciab.com/ContentManagement/ContentDisplay.cfm?), researchers ... reported that companies of all sizes, from those with 50 or fewer employees to those with more than 500, found their premiums were 10% to 20% higher over the last six months than they were at the beginning of the year."

Medical Cost Reference Guide (PDF) (Blue Cross Blue Shield Association)

76 pages; October 2004 revision. Excerpt: "A comprehensive collection of healthcare cost data addressing the critically important national issue -- access to affordable healthcare.... [W]e are happy to be releasing our third annual Medical Cost Reference Guide, which brings together some of the best secondary research available on the key drivers of healthcare costs."

BLS Report on Employer Costs for Employee Compensation - September 2004 (U.S. Bureau of Labor Statistics)

Excerpt: "Employer costs for employee compensation averaged $25.36 per hour worked in September 2004, the U.S. Department of Labor's Bureau of Labor Statistics reported today. Wages and salaries, which averaged $17.96, accounted for 70.8 percent of these costs, while benefits, which averaged $7.40, accounted for the remaining 29.2 percent."

 

 

ERISA OVERHAUL OF U.S. HEALTHCARE FOR SURVIVAL

"Zhou's Model of Prudent Health Care"

 

Ford Motor Co. Chief Executive Officer Bill Ford has assigned one of his top executives, Vice Chairman Allan Gilmour, to craft a proposal for fixing the nation's health care system. On December 2, 2003 he said: "But I do think we need a new model, because if the employers are getting choked with health care, and the hospitals are all losing money and the HMOs claim they're not making any money, then the system does not seem to be working very well".

 

Automotive Industry Threatened by Rising Health Insurance Costs According to William Ford, Jr. (CBSMarketWatch via Interactive Investor)

 

Excerpt: "Rapidly rising health-care costs have become an albatross weighing down the automotive industry, William Ford Jr., chief executive officer of Ford Motor, told industry executives Wednesday. Despite cutting costs by billions of dollars over the past few years, Ford Motor's medical liabilities are threatening its fiscal health .... .... 'In 2000, we paid $2 billion for employee health care,' Ford told the ... U.S. Chamber of Commerce. 'In 2003, those costs rose to $3.2 billion.'"

Health Insurers Getting Bigger Cut of Medical Dollars (Investor's Business Daily: Breaking News)

"The market is easy pickings for insurers, said Uwe Reinhardt, a health-care economist at Princeton University. He says companies are reluctant to haggle with their carriers.

"You could say it's their DNA, but it's not. It's the way they're structured. There's no push-back," Reinhardt said.

"You can stick any bill under their nose and they would pay it."

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

"The long-term economic health of the United States is threatened by $53 trillion in government debts and liabilities that start to come due in four years when baby boomers begin to retire. (Related graphic: U.S. economy threatened by aging of America).....

 

Comptroller General David Walker, the government's chief accountant, travels the nation warning of the impending crisis. "I am desperately trying to get people to understand the significance of this for our country, our children, our grandchildren," Walker says. "How this is resolved could affect not only our economic security but our national security. We're heading to a future where we'll have to double federal taxes or cut federal spending by 50%."

The Root of U. S. Healthcare Crisis

Jin Zhou, ERISAclaim.com

The Hearing at Senate Committee on Finance on 3-3-04, [View Video "Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance
or Transcript (PDF) (KaiserNetwork.org)]  revealed the mechanism, nature and extent of ERISA failure and nonenforcement as the reasons for "Growth in Bogus Health Insurance Plans Targeting Desperate Small Business Owners", as being concluded as "No the results are not good. It’s a tragedy." by Ann Combs, assistant secretary of DOL. The mechanism, nature and extent of ERISA failure and nonenforcement as presented at the Hearing are universally true and applicable to all health care claim denials and delays in managed care environment from all employer sponsored health plans as the root of U. S. healthcare crisis.

 

This is a 911 call on "healthcare 9/11 disaster"!

THE 9/11 COMMISSION REPORT (pdf)

 

"I just think that as a country, if we have a model that isn't working and a model that's driving jobs overseas, then we'd better take another look at it," Ford said.

 

Gary Cowger, president of GM's North American operations, urges speedy overhaul of U.S. health care (Forbes.com). He called for an overhaul of the U.S. health care system on Jan. 30, 2004, saying mushrooming costs threatened the survival of the country's struggling manufacturing sector.

 

GM to Report $60B in Future Health-Care Obligations (Quicken.com - News Center:)

 

Rising Cost of Health Benefits Cited as Factor in Slump of Jobs (The New York Times)

 

Kaiser Family Foundation Provides Transcript of Hearing on Unregulated Health Insurance Schemes (PDF) (KaiserNetwork.org)

 

Fake Insurance Leaves Millions in Bills Unpaid (Reuters, Mar 3, 2004)

 

Law As An Agent of Health System Change - [Abstract] [Full Text] [PDF]

(Health Affairs), March/April 2004; 23(2): 29-42.

 

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

 

Life and Health Insurers' Profits Skyrocket 213% in First Quarter 2004, Highest Increase in Decade, According to Weiss Ratings (BUSINESS WIRE)--Sept. 22, 2004

 

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

 

A.M. Best Special Report: Moderating Costs Favorably Impact Health Insurers' Earnings

 

Business Insurance - Health cost moderation boosts insurer profits: Best (Jan. 17, 2005)

 

"Helped by lower-than-expected health care cost increases, managed care companies’ net income increased by 40.3% for the first nine months of 2004, according to a report by Oldwick, N.J.-based A.M. Best Co. The 15 largest managed care companies reported total profits of $6.17 billion for the nine months ending Sept. 30, 2004, compared with $4.40 billion in the year-earlier period. "

 

 

Forbes.com: Ford urges "national solution" to U.S. health care (Reuters, 04.07.04)

"DETROIT (Reuters) - Ford Motor Co. called for a "national solution" to the problem-plagued U.S. health system Wednesday, saying drug companies were the only ones happy with the status quo.

Ford Vice Chairman Allan Gilmour was the latest U.S. auto industry official to sound the alarm about health care, amid warnings that mushrooming medical costs threaten the very survival of the nation's embattled manufacturing sector."

National Survey Shows Half of Employers Want Feds to Do Health Care System Overhaul (The San Diego Union-Tribune)

Excerpt: "Half of all employers believe the federal government should significantly overhaul or even scrap the nation's privately financed health care system, according to a new survey. Just over a third of all employers – 36 percent – believe the government should enact significant reforms to address the rising cost of health care, while 14 percent say health care should be nationalized into a federally financed system like Medicare."

 

Local Impact of GM Job Cut Plans (wlns.com)

"1/10/05- General Motors announces plans to reduce its US workforce by nearly 7% in 2005.  That means about 8,000 hourly and salaried positions at GM will be eliminated through attrition and retirement over the next 12 months."

What Kind of New Model for Speedy Overhaul
of U.S. Healthcare
Do We REALLY Need?

 

Points & Things Must Be Considered But Ignored By Most:

  1. Eliminating the need of universal one payer system to protect employer based healthcare system in order to make it practically working;

  2. Minimizing, if not completely eliminating, the need of multimillion dollar punitive damages to deter reckless claim practice;

  3. Reducing both claim administrative costs for health-care plans and healthcare administrative costs for health-care providers;

  4. Improving US healthcare quality through eliminating health care medical inflation and truly separating medical decision-making from business profit decision-making;

  5. Reducing the number of frivolous lawsuits by all parties for health insurance and medical malpractice/tort actions;

  6. Promoting the consistent treatment of claimants solely based on ERISA law and the plan SPD;

  7. Providing a nonadversarial method of claims settlement through ERISA claim education and ERISA appeal practice for all involved;

  8. Minimizing the cost of claims settlement for all concerned and involved solely based on ERISA law and specific ERISA plan provisions instead of third-party managed-care contracts and profit-making guidelines;

  9. Enhancing the ability of plan sponsors and trustees of healthcare benefit plans to manage their funds expertly and efficiently by preventing premature and costly judicial intervention in their decision-making processes;

  10. Enhancing the ability of plan sponsors and trustees of healthcare benefit plans to correct their errors or omissions, or at the same time, an opportunity to convince a disgruntled or disappointed claimant (patient and healthcare provider) that he or she is incorrect based on federal law and the plan provisions;

  11. Enhancing the ability of plan sponsors and trustees to interpret health-care plan provisions of individual plan SPD instead of non-applicable and non- controlling third-party managed-care contracts and profit-making guidelines; and

  12. Helping assemble a factual records of healthcare medical decision-making and plan benefits decision-making that will assist a court in reviewing the fiduciaries actions and possible medical malpractice actions.

 

Zhou's Model of Prudent Health Care Will Revive Employer-based Healthcare System:

 

"Zhou's Model of Prudent Health Care"
Are All Consultants Corrupt? (Fast Company)

USA: GM chief talks health care as Republicans convene: Auto News

"Wagoner reportedly said much of the discussion in Washington tends to centre around a complete, free-market system on one extreme, and a national health care programme [similar to the UK’s National Health Service] on the other.

 

"I suspect we're not going to end up with either one of those solutions," he told the Associated Press. "So if we could get people working on stuff in the middle ... I think there'd be some real improvements made."

Jin Zhou Identifies "ERISA Failure" That Killed U.S. Healthcare

"Failure of Imagination" Again?

 

    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"

(GM Current Model: $5.1 billion/yr, $1,400/vehicle)
(GM says health care obligation hit $67.5 billion in 2003)

Rx-1  $$$$$$$$$ERISA"Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance
$$$$$$$$$$  Rx-2

General Motors National Benefit Center

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)

 

 

DOL-Reporting and Disclosure Guide for Employee Benefit Plans (pdf)
Compliance Assistance for Group Health Plans (Top 15 Tips)

950,000 MD's Settled With Aetna & Cigna on ERISA
"Aetna and CIGNA Settlement Secrets"
ERISA Certification Programs for Maximal Reimbursement

What You Should Know about Filing Your Health Benefits Claim
HIPAA Nondiscrimination Requirements Frequently Asked Questions

 

Inquiry on Medicare Finds Improper Limits on Choices of Health Care Providers (The New York Times; one-time registration required)

Excerpt: "Federal investigators said Monday that the Bush administration had improperly allowed some private health plans to limit Medicare patients' choice of health care providers, including doctors, nursing homes and home care agencies."

Medicare Demonstration PPOs: Financial and Other Advantages for Plans, Few Advantages for Beneficiaries GAO-04-960, September 27, 2004

Abstract    Highlights-PDF    PDF 

 

 

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."

 

USATODAY.com - Hospitals Sock Uninsured with Much Bigger Bills

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

 

 

MSNBC - Employers see health care premiums up 17% in 2004

 

Aon Forecast: Rise in Medical Plan Trend Rates to Taper Off Slightly, But Double-digit Increases Will Continue in 2004

"According to Aon Consulting's Spring 2004 Health Care Trend Survey, employers can expect more of the same: double-digit increases for all types of medical coverage, with HMOs and POS plans forecast to increase at 14.1 percent."

Benefit Spending Drives Compensation Costs (BenefitNews.com)

Employer Costs for Employee Compensation--December 2003 02/26/2004 (Bureau of Labor Statistics)

Mass layoffs up in January 2004 (Bureau of Labor Statistics)

 

Ford said he has no preconceived notion of how to solve the health care crisis.

 

Cowger proposed no solution to the health care problem in a speech to an international automotive conference sponsored by J.D. Power and Associates, an influential industry research firm.

 

This is the exact new model what Ford Motor, GM and U. S. employers are looking for:

 

ERISA OVERHAUL OF U.S. HEALTHCARE FOR SURVIVAL

"Zhou's Model of Prudent Health Care"

 

  1. Cut 50 percent of the cost of health care for your company and improve health care service access and qualities at the same time;

  2. Cut 50% of the cost of employee benefits administration and improve the quality of benefits management and satisfaction of employees;

  3. Cut, fundamentally and voluntarily, 50% of the cost of health care by providers through unprecedented teamwork with health care providers, employees, employers and TPA's by ERISA claim procedure compliance;

  4. Consulting in ERISA SPD and claim procedure compliance to truly automate health benefits management and cost containment;

  5. Educating in ERISA SPD and claim procedure and the strategies for your executives, benefits managers/HR staff, employees and TPAs in truly cutting cost of health care and minimize noncompliance risks;

  6. Consulting with ERISA strategies for executives and benefits managers as well as TPA's in ultimate benefits automation and self services.

  7. Abandon completely current managed care model and mechanism, create a new national health care model, "Zhou's Model of Prudent Health Care", with fiduciary compliant, doctor-patient and employer-employee trusted care, where the employers completely control plan funding and spending, employees completely control access and quality in health care, physicians completely control healthcare quality, a new model with administration simplicity, complete fiduciary compliance with all applicable federal and state laws, ERISA claim regulation and state utilization and external review laws, with transparency, free choice and free access with prudence, everyone takes his/her own responsibilities.

  8. This "Zhou's Model of Prudent Health Care" includes completely new but extremely simple benefits design, compliance and mathematical modules, with ultimate goals of 50% health-care expenditure saving and free access to quality health care by eliminating unnecessary and self-inflicted administrative costs and conflicts as well as managed care crisis.

  9. Managed care restricts and limits access to the quality care by someone else other than patients and physicians resulting in consumer's backlash with distrust and stimulating escalated health care costs, while "Zhou's Prudent Health Care Model" will let patients and physicians decide prudently on access and utilization of quality medical care under completely new ERISA compliant, transparent and prudent benefits schedule.

 

We will help you to strategically and operationally accomplish these goals when conventional and traditional thinking pattern, legislation and industry practices have failed undisputedly in controlling skyrocketing health care costs.

 

Licensing of ERISA-Covered
Benefit Plan Administrator?

New York State Seal
STATE OF NEW YORK
INSURANCE DEPARTMENT
25 BEAVER STREET
NEW YORK, NEW YORK 10004

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

 

"Discretionary Clause" >> "Discretionary Spending" >> "Discretionary Medical Inflation" >> "Discretionary Insurance Robbery" >> Discretionary Medical Killing >> "Discretionary Universally Uninsured"  >> "Discretionary Jurisdiction Non-enforcement"  >> U.S. Healthcare Crisis!

 

Employer Health Plan Nightmares ... and Other Things That Go Bump in the Night (Chang Ruthenberg & Long PC)

Excerpt: "Nightmare #1: The Phantom SPD

For insured welfare plans, including most health insurance arrangements, the insurance company generally provides a booklet describing available benefits and limitations, cards for your employees, and a formal contract or policy that is signed by the employer. Many employers hand out the benefit booklets to eligible employees, but they do nothing further....
."

 

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

 

FEATURE-US companies mad as hell at HMO premiums (Forbes - Oct 16, 2003)

 

GM urges speedy overhaul of U.S. health care (Forbes.com)

"LAS VEGAS, Jan. 30 (Reuters) - General Motors Corp. (nyse: GM - news - people) called for an overhaul of the U.S. health care system on Friday, saying mushrooming costs threatened the survival of the country's struggling manufacturing sector."

 

"For the first time in nearly 20 years, small businesses say soaring worker health costs, not taxes, are their biggest headache. Taxes had been No. 1 since 1986." (USA Today 4/20/2003)

 

"The skyrocketing cost of health care is one of the toughest challenges facing Ford Motor Co., Chairman and CEO Bill Ford Jr. said Friday......

The solution to the health care problem will require government and business to work together in a new way, Ford said. " (AP  05/30/2003)

 

Ford Exec Gets New Task: Solve National Health Care Crisis (Detroit Free Press) (12/03/2003)

 

GM stocks up ahead of labor talks (MSNBC), Union rejects GE healthcare proposal (CNN), and Chrysler Shifts Additional Benefit Costs to Salaried Retirees (Detroit Free Press via International Foundation of Employee Benefit Plans) while Health care experts are not optimistic (Conroe Courier).

 

Healthcare Coverage a Growing Issue in Labor Negotiations (Washington Post)

 

"There's really not very much cost-control going on at all other than employers moving to cost-sharing," as found and concluded by the latest research,  in 12 nationally representative communities from site visits and interviews with healthcare executives, employers and policymakers conducted in 2002 and 2003 by Center for Studying Health System Change (HSC).

 

No relief for health-care premium sufferers, 50% cost increase expected in 3 years, ...(Chicago Tribune)

 

HMOs Could Raise Premiums By 18 Percent Next Year (Dow Jones News Wires via St. Louis Post-Dispatch)

 

Aon, Marsh Forecast Health Cost Increases Above 16% (BenefitNews.com)

 

What's Your Strategy for Controlling Healthcare Costs? (PDF) (Aon Consulting/Radford Surveys)

 

43.6 Million People in the United States Lack Health Coverage, Census Bureau Figures Say (KaiserNetwork.org)

 

Towers Perrin Projects Fifth Consecutive Year of Double-Digit Health Care Cost Increases in 2004

 

Business Survey Finds Employers Faced with Healthcare Cost Increases Exceeding Ability to Pay (acordia.com)

 

More Labor Conflicts Expected Over Health Care Costs (AP via SFGate.com)

 

Cost of Private Health Insurance Lost in National Healthcare Coverage Debate (Los Angeles Times; one-time registration required)

Excerpt: "The rising cost of private health plans "has been like a stepchild to all the other problems," said Len Nichols, a health economist with the nonpartisan Center for Studying Health System Change. "Everyone knows it's there, but no one wants to talk about it."

Insurance Disputes Might Leave Patients Covering More Health Costs (KaiserNetwork.org)

Excerpt: "While in the past, doctors' and hospitals' 'threats' to end contracts with certain health plans mostly amounted to 'negotiation tactic[s],' recently many doctors and hospitals are 'leaving offers on the table' and 'betting that their patients will pick different health plans or pay out-of-pocket for services,' the Chicago Tribune reports."

1/3 of Workers Uninsured in 2001 Were Employed by Large Firms
Full Text of Report (pdf) (The Commonwealth Fund)

Press Release   Summary   Report

Excerpt: "Thirty-two percent of workers lacking health coverage in 2001 were employed by large firms, up from 25% in 1987, a new Commonwealth Fund report finds.... The report, The Growing Share of Uninsured Workers Employed by Large Firms, was coauthored by Sherry Glied, Ph.D., and Sarah Little of Columbia University and Jeanne Lambrew, Ph.D., of George Washington University."

Fewer Employees Have Health Insurance at Large Companies (USA Today)

 

85 Million Americans Had No Health Insurance At Some Point During Four Year Period Studied (The Commonwealth Fund)

 

Job-Based Health Insurance in the Balance: Employer Views of Coverage in the Workplace (PDF) (The Commonwealth Fund)

 

Overview: Managed Care Insurer Liability Among the States (National Conference of State Legislatures)

 

The Battle Over Benefits (Workforce.com)

Excerpt: "The cost of health care is strangling companies, prompting strikes and leaving an increasing number of Americans without any coverage at all. Some companies are coping, but experts fear that a sick system will have to come close to collapse before there is reform."

Now "employers moving to cost-sharing" as the last hope for U.S. healthcare heart attack resuscitation was given a prognosis of "future federal budget deficits of more than $44.2 trillion, being overwhelmed by the 'baby boom' generation's future healthcare and retirement costs. (CNN 05/29/2003)

 

Opinion: Health Savings Plans Unlikely to Achieve Lofty Goals (Paul Ginsburg, published by the Center for Health System Change)

 

As reported by CNN on May 29, 2003, "If the problems aren't corrected, the study shows, the already huge projected shortfall could grow to $54 trillion by 2008 and keep getting larger every year thereafter."

 

With "Zhou's Model of Prudent Health Care" and our unique and unprecedented expertise and experiences in ERISA and health care consulting, educating and claims recovery, we will prove to you that US health-care crisis, including your company health care crisis, can be fixed if we are truly committed and persistent in preventing and fixing this potentially inevitable health-care crisis triggered national economy ($44 trillion deficit)  and labor crisis in this country.

 

O'Neill: Health costs can be halved  (post-gazette.com)

 

Report of the ERISA Advisory Council's Working Group on Fiduciary Education and Training (U.S. Department of Labor, Employee Benefits Security Administration)

 

Detroit's Healthcare Crisis--and Ours (Geoffrey Colvin on Fortune.com) will take you to "Pay or Play" Ground if  American business leaders and owners don't act now.

 

Gettelfinger, Gilmour: Nation must solve health care crisis(Biloxi Sun Herald, MS)

 

GM urges speedy overhaul of U.S. health care (Forbes.com)

"LAS VEGAS, Jan. 30 (Reuters) - General Motors Corp. (nyse: GM - news - people) called for an overhaul of the U.S. health care system on Friday, saying mushrooming costs threatened the survival of the country's struggling manufacturing sector."

Health-cost surge hurts profits, jobs (February 08, 2004)

"Ford Motor Co. Chief Executive Officer Bill Ford, in Chicago last week for the auto show, said health care costs are his biggest challenge.

 

"We are paying more for health care per vehicle than we are paying for steel," he said, adding there is no easy solution.

 

Ford spent $2.8 billion - $700 per vehicle - in 2002 on health care for U.S. employees, retirees and dependents."

Pay or Play Bill in California Won't Work Without Price Controls (The Foundation for Taxpayer and Consumer Rights)

 

Cost Shifting: New Myths, Old Confusion, and Enduring Reality (Health Affairs)
Excerpt: "Instead of focusing on the symptom of cost shifting, we should be focusing on the causes."

 

Testimony of Consumers Union on Consumer-Driven Health Care (Consumers Union)

Excerpt: "So-called 'consumer driven' health care plans, which have defining features of high-deductible coverage and (possibly) tax-advantaged employer contributions to health reimbursement or savings accounts, may create serious problems for the U.S. health care system. Consumers Union believes that this coverage is misnamed, misguided from a policy perspective, and a dangerous distraction from the need to solve the health insurance crisis that faces 43.6 million uninsured consumers ..."

Aon's Fall 2003 Health Care Trend Survey (Aon Consulting)

 

2004 Segal Health Plan Cost Trend Survey (PDF) (The Segal Company)
 

Transit, grocery, law labor unrest roils California (AP)

 

Kroger strike, Medical cost to blame (wvgazette.com)

 

Rising Health-Care Costs at Heart of Labor Strife in Southern California (Los Angeles Times; one-time registration required)

 

From wages to health care, Medical coverage first and last issue in labor contract negotiations, (Sunday Gazette-Mail - Business)

“In labor negotiations now, the first day you talk about health-care coverage, and the last day you talk about health-care coverage,” said Jim Bowen, president of the West Virginia Labor Federation. “It’s the No. 1 issue and the last issue. The costs are spiraling, and health insurance considerations come ahead of everything else.”

Opinion: a Watershed Strike (Kelly Candaele & Peter Dreier in The Nation)

 

Grocery strike, spiraling health costs are very close to home (SignOnSanDiego.com)

 

(Jin Zhou, ERISAclaim.com) "Wal-Mart bare-bones benefits strategy and Band-Aid fix and solutions to the U.S. healthcare and labor crisis will temporarily stop "local bleeding" (health care costs per employee 40% less than the U.S. average, Wysocki/Zimmerman, Wall Street Journal, 9/30).for no more than two years and will inevitably result in unintended backslash accelerating employer-sponsored health care benefits system collapsing and labor disasters.

 

Because Wal-Mart bare-bones benefits package discourages and precludes noncatastrophic medical claims but covers and "promotes" the catastrophic medical claims with no lifetime cap, that will practically quadruple the catastrophic medical claims in two years, with an upfront benefits saving by 40% and catastrophic benefits cost increase by 400% in the end.

 

Wal-Mart company spokeswoman Sarah Clark tells Connect that Wal-Mart's health plan does not cover employees' everyday health expenses like flu shots, eye exams and child vaccinations. Further, plan deductibles can reach as high as $1,000 and premiums have risen 50% over the past two years. However, the company does cover catastrophic medical claims, with no lifetime cap. According to Clark, who maintains employees prefer the plan design. "Generally, our associates are more concerned about the cost of the bimonthly premiums than they are about the inclusion of [traditional health expenses]," she explains. "Thus, we offer a strong catastrophic plan that is affordable to many, rather than a richer plan that is affordable to only a few."

 

However according to Aon Consulting, "What's Your Strategy for Controlling Health Care Costs?"(pdf): "27% individuals spend 85% dollars, 33% expenses for preventable conditions, 50-60% hospital admissions due to chronic conditions, This is where the money is! "(page 24)

 

Wal-Mart is nation's number one employer, if 33% of preventable conditions and 60% of hospital admissions become eligible for the catastrophic medical claims for another 27%, 54% of Wal-Mart Associates in two years, everyday low-price logo may not hold the truth." (Jin Zhou, ERISAclaim.com)

 

Patient Cost Sharing: How Much is Too Much? (Center for Studying Health System Change)

 

Out-of-Pocket Costs Affect Sicker, Low-Income Workers More, Study Says (KaiserNetwork.org)

 

JS Online: Workers paying higher health care deductibles

The "number one driver" of health care costs is the amount of health care services employees use, Heaps said. "Discretionary spending is driving us crazy."

This is why:

 

  1. A $1.0 Trillion Nuclear Solution to Our Nation's Health-care Crisis

  2. ERISA Demystified for Providers, Insurers, Employers, TPAs, Patients, Regulators and Legislators

  3. U.S. healthcare cost spiral seen continuing (Reuters Health via blueshieldca.com)

  4. Another main reason for failures in health care costs cutting at this critical time in this country is that strategies and measurements employed so far are mostly against health-care providers, claims submitters, or completely without truly understanding health-care provider's "pain-and-suffering" in managed care claim denials and appeals. We are the ultimate experts in health care provider claim denial and appeals, which makes us the most uniquely qualified and credible experts in 50% health-care costs cutting AFTER other "real experts" exhausted their expertise.

  5. "Pioneer" as defined by Webster's Unabridged Dictionary

    "1. a person who is among those who first enter or settle a region, thus opening it for occupation and development by others."

    "2. one who is first or among the earliest in any field of inquiry, enterprise, or progress: pioneers in cancer research."

 

 

Fortune.com - Magazine - How to Defang the Health-Care Cost Monster

"All those impulses are understandable. But all involve cost shifts. And in the end, cost shifts aren't about solving the problem; they're about making health costs somebody else's problem, a situation that will always favor those with political power and beggar the little guy.

.....

 

But the first thing that has to change is the national mindset. We can't keep pushing costs to the other guy; we need to reorganize health delivery in ways that cut costs while improving quality. That won't be easy, because every dollar of health-care "waste" is somebody's dollar of income. Still, until we start thinking clearly about our goals, we're just playing make-believe."

Most Large Employers Use Consultants for Benefit Plan Design, Actuarial Work and Vendor Selection (The Adviser)

Excerpt: "Eighty percent of the 408 respondents say they use consultants, most often for their health plans, although 55% employ them for their disability plans as well. Surprisingly,

Excerpt: "Eighty percent of the 408 respondents say they use consultants, most often for their health plans, although 55% employ them for their disability plans as well. Surprisingly, fewer than half call in consulting companies for help with retirement plans, both defined benefit and defined contribution, while 30% use consulting services for flexible benefit plans and 22% for wellness programs."

Zhou's Prophecy on Current U.S. Healthcare Crisis and Projected $44 Trillion Federal Budget Deficits:

 

  1. As the study, commissioned by commissioned by then-Treasury secretary Paul O'Neill, projected at $44 trillion as future U. S. federal government is facing and being overwhelmed by the 'baby boom' generation's future healthcare and retirement costs, and the deficit could grow to $54 trillion by 2008 and keep getting larger every year thereafter if the problems aren't corrected, and an assessment by Mr. William Ford, Ford Motor Co., Chairman and CEO, that pensions problem as the world's No. 2 automaker's another concern, will go away when the stock market improves, that leaves healthcare as the only main disaster that needs to be fixed today instead of tomorrow;

  2. As studied and concluded by Center for Studying Health System Change (HSC) in 2003 that "There's really not very much cost-control going on at all other than employers moving to cost-sharing" with the prognosis of $54 trillion Federal budget deficits by 2008, if American business leaders and the Congress continue to defend our mistakes and failures, John Q.., out from Hollywood (play the Preview from "View the trailer") will lead American workers in putting our Congress "under new management";

  3. But none of the above will happen because we, American people and leaders, are not that stupid!!! Our nation, the best country on the planet, is not going to be Healthcare-Consumer-Driven and White House + Congress-Directed into A $54 trillion hole;

  4. Something new is going to happen, it's just a matter of time, my prediction is that "Zhou's Model of Prudent Health Care" will be the inevitable solution, and if that's true, would you rather to be the first one or last one on the winning side?

  5. Any long-term strategies for countering rising healthcare costs will inevitably fail unless employers fully understand the most important cause of managed-care failure - ERISA failure.

 

ERISA FAILURE SYNDROME (EFS) has fundamentally and drastically eroded not only our health-care system, pension and retirement, but also our nation's labor market, US economy, and American dreams as well as American value and security.

 


Survey: Health Care Reform a Major Issue for Voters


Fund Publications and Journal Articles (All Publications Are Free)

The Affordability Crisis in U.S. Health Care:
Findings from the Commonwealth Fund

Biennial Health Insurance Survey

Archive of March 29 Webcast

Findings from the Health Insurance Survey and Policy Implications: Karen Davis, President, and Sara Collins, Senior Program Officer, The Commonwealth Fund
PowerPoint Slides

Labor and Consumer Perspectives on the Findings: Gerald Shea, Assistant to the President for Governmental Affairs, AFL-CIO

PowerPoint Slides

Business Perspectives on the Findings: Helen Darling, President of the National Business Group on Health


PowerPoint Slides


Law As An Agent of Health System Change - [Abstract] [Full Text] [PDF]

(Health Affairs), March/April 2004; 23(2): 29-42.

 

Most importantly, American employers have been mistakenly and detrimentally believing that they have less or no control over healthcare costs for their employees and retirees in today's healthcare market by delegating their power and fate to someone else, in hope that more managed care discounts, employees cost-shifting, canceling retiree's benefits and tax incentives will save and avoid their crisis in healthcare, labor and pension survival. Their "hands free" "ASO" shortcuts and "mind free" ERISA pre-emption privilege in the past decades have brought them double digitals overall healthcare costs explosions and labor strikes!

 

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."

Under ERISA, only American Employers have complete and ultimate control over funding and healthcare price and costs.

 

As both GM and Ford have seen the "Code Blue" that "mushrooming costs threatened the survival of the country's struggling manufacturing sector", American employers must get out fast from the dead tunnel of managed care and wholeheartedly quit defending and fantasizing the past fatal mistakes and failures in ERISA benefits administration. True leaders must get their minds and hands on employee benefits overhaul through ERISA compliance to cut 50% in costs and expand benefits and coverage at the same time!

 

Any health care proposals and solutions to current U.S. healthcare, benefits, labor and pension crisis without ERISA compliance and education will backfire with more cost explosions and union strikes, and will threat the survival of the country's struggling economy, labor and pension security.

 

"Zhou's Model of Prudent Health Care" is an extremely valuable strategy and initiative for a truly outcome oriented overhaul, instead of the popular and current tweaking of the existing failing health care system, should conventional experts and strategies fail, in a tmely fashion, to develop ERISA compliance, costs savings, benefit increases, as well as a quality and safety oriented overhaul for U.S. economic survival.


A speedy strategic vision and mission overhaul for its survival is not to tweak the existing failing and hopeless healthcare system with the existing managed-care model that has created double-digit mushrooming costs and destroyed the faith and trust in our healthcare system, primarily sponsored by American employers, with GM being the No. 1 payer at a price tag of $4.5 billion each year.


The cruel facts and warning intelligence are so clear that nation’s health care survival cannot rely upon the popular and conventional strategies and experts based on the principles of the managed care model by employee burning through cost sharing and shifting, tax incentive blood transfusions and segmental reengineering in disease management and provider contracting strategies.


As proposed in “Zhou’s Model of Prudent Healthcare” solution, any strategy to improve safety, quality and efficiency of the health care system that serves our beneficiaries for American employers, has to be fully compliant with ERISA, rather than the current cosmetic and cursory compliance, by cutting costs and doubling benefits at the same time.


Zhou's Model and strategies are designed to enable and empower employees and beneficiaries to voluntarily, instead of confrontationally, make their health decisions and choices for saving healthcare costs, and to invite healthcare providers to voluntarily provide the best quality of healthcare at a reasonable and minimal expense.

 

Any strategies, placing employees and beneficiaries and healthcare providers in a confusing or punitive way and a confrontational fashion, as the current managed-care model has been doing, will backfire with detrimental consequences. As health-care benefits sponsored by any American employers are primarily provided to benefit employees for the purpose of retaining the best labor force in the market and rewarding healthcare providers for delivering the quality, safety and perceivable satisfaction of healthcare at reasonable and competitive prices. By reviewing the current managed-care litigation landscape, as outlined and summarized at my website, ERISAclaim.com/Courtwatch.htm, we would all agree that dissatisfactions and confrontation from American workers and healthcare providers are much greater than the perceived and proclaimed success of the current managed-care model.


There are hundreds of thousands of strategies and proposals out there in the market, but they are all conventional and incidental tweaks and symptomatology remission therapy to preserve and defend the current fatal healthcare failure, invented and promoted by conventional experts and professionals in the development of the managed care market and history in the past two decades. “Administrative Service Only” (ASO) contracting and Managed-care “Deep Discounts” have created undisputed overall out-of-control skyrocketing costs under a false promise of managed-care savings resulting in less and less quality and efficiency in the healthcare delivery system. At the same time, $4.5 billion from GM and $1.55 trillion from U.S. have rewarded most efficiently the individuals and industries with the greatest financial success, but left the American worker at the breaking point in the healthcare managed-care environment as well as more and more uninsured American workers.


The “conventional experts and strategies” in creating this managed-care crisis, while disregarding ERISA compliance, shall be the target, instead of the driver, of U.S. Healthcare ERISA overhaul for survival.


ERISA has been poorly understood by American employers in the past 28 years. The ERISA diagnosis and solutions in Zhou’s Model of Prudent Healthcare, as the solution to U.S. Healthcare overhaul, are for a quantum change with a nuclear effect for empowering U.S. employers to truly utilize ERISA to control healthcare costs and benefit U.S. Employees and their families.


We provide educational and consulting solutions to employers/plan sponsors, insurers and TPA's with compliance assistance to reduce  administrative and healthcare costs and risks through compliance of ERISA to fundamentally solve your healthcare crisis and to avoid potential labor crisis and future U.S. budget deficit ($44 trillion deficit).

 

****************************************************************

****************************************************************

 

"Failure of Imagination" & Solutions?

THE 9/11 COMMISSION REPORT (pdf)


Healthcare Fahrenheit 9/11 Pre-Commission Report

 

 

 

 

 

Jun 30, 04  Application & Proposed Order to Hear Motion to Include Parties to Thomas & Solomon Actions Within the Scope of Stipulated Protective Orders on Shortened Time

 

"CHICAGO — Blue Cross and Blue Shield Association (BCBSA) today announced total enrollment in 41 independent Blue Plans across the country reached 88.8 million members at the end of 2003, up from 85.3 million at the end of 2002.  This marks the 9th consecutive year that the Blue Cross and Blue Shield System has recorded enrollment growth."

CLASS ACTION LAWSUITS BY UNINSURED PATIENTS BROUGHT AGAINST SIX MORE NONPROFIT HOSPITAL SYSTEMS AROUND THE COUNTRY - 07/09/04 (hospitalpricegouging.org)

 

Lawsuit Filed Against National “For-Profit” Hospital Groups To Protect Uninsured Patients From Hospital Price Gouging And Unconscionable Billing Practices - August 5, 2004 (hospitalpricegouging.org)

 

Class action accuses Sutter of overcharging the uninsured Article from the Sacramento Business Journal (hospitalpricegouging.org)

Subcommittee on Oversight and Investigations, House Energy and Commerce Committee “A Review of Hospital Billing and Collection Practices”, June 24, 2004

Health-care crisis and the failures encountered nationwide as alleged in class-action lawsuits have set off alarms and High alert for ERISA failure & crisis.

 

"Failure of Imagination" Again?

"John Q.
ERISA
Enforcement"

 

 

What is "Zhou's Model of Prudent Health Care"?

Please e-mail for details  or

Call:  630-736-2974

 

U.S. Health-care Crisis
& ERISA Criminal Enforcement



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

 

ERISAclaim.com - 950,000 MD's Settled With Aetna & Cigna on ERISA

 

ERISAclaim.com:  ERISA Certification Programs
for Cost-Saving & Reimbursement by Compliance

 

 

DOL + DOJ Enforcement of ERISA

 

    

 

HHS Works with ERISA (+77 Millions/4 Yrs)

 

 

"Cut 50 percent of the cost of health care"

"This is not some wild theory"

"We can cut 50 percent of the cost of health care in this nation and improve service at the same time. This is not some wild theory",  according to the former U.S. Treasury Secretary Paul O'Neill, as reported by The Hartford Courant on September 24, 2002 .  "O'Neill insists the problem is not with people, but systems - systems that invite medical errors, systems that penalize health care professionals for making honest mistakes, systems that create the mind-numbing complexity of reimbursement for providers, systems that reward too much treatment and punish efficiency".

 

"The latest Harvard & RAND study 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 reported: "....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."

 

 

Testimony of Consumers Union on Consumer-Driven Health Care (Consumers Union)          Click Here for full testimony (PDF format only)

Excerpt: "So-called 'consumer driven' health care plans, which have defining features of high-deductible coverage and (possibly) tax-advantaged employer contributions to health reimbursement or savings accounts, may create serious problems for the U.S. health care system. Consumers Union believes that this coverage is misnamed, misguided from a policy perspective, and a dangerous distraction from the need to solve the health insurance crisis that faces 43.6 million uninsured consumers ..."

Greenspan Pushes Social Security Cuts (AP via Washington Post)

Text of Alan Greenspan's Statement to Budget Committee on Effect of Baby Boomer Retirements (U.S. House of Representatives Budget Committee)

 

U.S. Healthcare Crisis Is Driven By Medical Inflation in Pricing & Costs Stimulated by MCO/PPO/HMO Discount and Capitation While Promoted and Guaranteed By ERISA Failure

 

HMO & PPO Managed Care Contracting to  Disregard & Substitute ERISA SPD & Claims Procedure Is The Primary & Inevitable Cause of Medical Inflation.

 

Billllll & Denialllll  =  Billllllllllllllllllll + Denialllllllllllllllllllllllll  =
Billllllllllllllllllllllllllllllllllllllllllll++Deniallllllllllllllllllllllllllllllllllllllllllll =
U.S. healthcare crisis!!!="The Health Care Misery Index"

 

The cost driving factors are evident in these three cases in the context of ERISA and managed care:

 

FALLICK v NATIONWIDE MUTL INS

 

HCA Health Services of Georgia, Inc. v. Employers Health Ins. Co.

 

McDougall vs Pelchart, et al (Aetna, UPS)

 

ERISA Failure + "PPO discounts" = "Price Gouging" or Medical Inflation;

 

Without PPO discount = "dual fee schedule" " insurance fraud";

 

With PPO discount = "charging more" against uninsured;

 

Indigent discount for "44 - 82 million uninsured" = "dual fee schedule" insurance fraud;

 

More PPO discounts/"savings" = more provider's price gouging/inflation;

 

From PPO's, silent PPO's and incentive HMO's to hospital networks and physician IPA's, price/discount negotiation power wars between managed-care organizations and health-care providers are unfolding more dramatically but invisibly than terror war that are resulting in unprecedented medical inflations.

 

GAO finds higher health care costs in Milwaukee (AP Wire) 08/23/2004

 

"The GAO said one factor in the high costs was that hospital networks and physicians had more leverage that insurers in negotiating prices.

 

"This must change," Barrett, who was in Congress when he requested the report, said in a statement. "We need to work together and find ways to make health care more accessible for everyone."

Full Text of 'Improving Health Care: a Dose of Competition' (PDF) (Federal Trade Commission; Department of Justice)

361 pages, Excerpt: "Conclusion. Remedies are a critical issue in implementing an effective competition policy. If remedies are inadequate, they will not have a credible deterrent effect. If remedies are excessive, they will over-deter, and discourage conduct that is actually permissible. Balancing these considerations is a difficult task." (PAGE 20)

More managed care = more lawsuits and more legislations.

 

MGMA survey highlights reimbursement disparities (American Medical News)

"Practices reported lower actual payment rates than those contracted for nine of the 10 common CPT codes examined. - Aug. 9"

Health care discounts vary widely (JS Online)

County's audit provides rare look into hidden pricing arrangements

Hearing: A Review of Hospital Billing and Collection Practices

Subcommittee on Oversight and Investigations, June 24, 2004

Dr. Sara Collins, Senior Program Officer, The Commonwealth Fund

Conclusion

"......In the end, small policy changes will need to be accompanied by broad policy solutions that address the root cause of the affordability crisis in U.S. health care—policies that would expand access to affordable health insurance and reduce the rate of health care cost inflation."

 

 

CLASS ACTION LAWSUITS BY UNINSURED PATIENTS BROUGHT AGAINST SIX MORE NONPROFIT HOSPITAL SYSTEMS AROUND THE COUNTRY - 07/09/04 (hospitalpricegouging.org)

 

Lawsuit Filed Against National “For-Profit” Hospital Groups To Protect Uninsured Patients From Hospital Price Gouging And Unconscionable Billing Practices - August 5, 2004 (hospitalpricegouging.org)

 

Proposed class action suit against hospital group filed in Miami (AP Wire | 08/05/2004 )

 

"According to the class-action complaint, HMA charged Quintana $3,060 for a three-hour visit.

 

That same visit for a person with insurance would cost around $900, said K.B. Forbes, executive director of Los Angeles-based Consejo de Latinos Unidos, an advocacy group that assists Hispanics."

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

 

"Hospital pricing strategies are driven by a complex mix of differing payment schemes and contracting arrangements as well as market forces.

 

With the advent of selective contracting and the growth of managed care in the US, the practice of negotiating discounts with hospitals has become widespread.  In this environment the gap between list and net prices has widened.  Contracting, combined with market forces, largely drives hospital net prices.  Consequently, most insurers, policymakers, and researchers have focused on net prices.  However, there are a number of factors that have kept hospital list prices important in overall hospital pricing and which have contributed to the rapid run-up in list prices.  These factors include:

 

·        Not all third party payors have contracts with all providers (i.e., Some third parties pay list prices or charges).

·        Many third party contracts include payment formulae where the discount is applied to list prices (or charges).

·        Many third party contracts (including Medicare) have stop-loss provisions that pay on the basis of list prices (charges) above a certain threshold.

·        In many cases the stop loss threshold is based on list prices (charges).

·        Not all insured patients are covered by a third party at every hospital (e.g, for out-of-network use)

·        Some patients have no insurance coverage (self-pay patients) and do not have access to negotiated discounted prices at any hospital

 

Since most hospitals can increase their net revenue (from private insurers, Medicare, and workers comp plans) by raising their list prices, there is a strong incentive to keep increasing list prices.  Indeed, data show that list prices have increased rapidly and substantially in recent years."

 

 

"Inflation Central is a dynamic resource for news about health care inflation trends. Visit this site frequently to view articles, surveys, and strategies published by ArlenGroup and other leading providers of health care and business insurance information."

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

 

California Nurses Association: New Study Documents High Markups on Hospital Charges

"OAKLAND, Calif.--(BUSINESS WIRE)--Sept. 8, 2004--New research on pricing practices of over 4,000 hospitals across the U.S. documents that huge markups in charges to patients, especially for prescription drugs, medical supplies, and surgeries, are a major factor in exacerbating the nation's health care crisis and the pricing scandal that has prompted hearings, lawsuits and a growing public outcry.....

 

Overall, the nation's 100 most expensive hospitals marked up their gross charges an average of 673% over their costs -- meaning the average top 100 hospital would bill $673 for a patient's case where the actual costs were $100."

USATODAY.com - Hospital sues insurer for not paying full charge

 

USATODAY.com - Hospital bills spin out of control

"The debate over hospital charges is part of the fallout from the rise of managed care, when insurers drove down payments to doctors and hospitals with a take-it-or-leave-it attitude. In response, hospitals banded together in systems, giving them larger market share and bargaining power. Many hospitals successfully demanded bigger payments by telling insurers to pay up or they would stop accepting their patients."

 

"We raised charges 45%," Callanan says. "We only collected $8 million more."

"The national controversy over whether hospitals overcharge uninsured patients while giving steep discounts to big insurance companies hit the courts in New Jersey yesterday.

A class-action suit filed against the Saint Barnabas Health Care System alleges the hospital network charges "inordinately inflated rates" to people without insurance, and then uses "abusive, harassing tactics" to collect the money."

While facing unsustainable healthcare crisis and dissatisfied of insurers and TPA/MCO's performance, American employers started their own E-bay style "more discounts" bidding war among their ASO/TPA market, resulting more and deeper discount up to 50-70% PPO discount/"savings", which in turn, must translate into hospital new UCR (list price), "Price Gouging" discovered by Glenn Melnick, Ph.D, presented to Subcommittee on Health Hearing on the Uninsured, Tuesday, March 09, 2004.

 

BE ALERT!

 

That was then for a set of factors that includes low deductibles of no more than $500 for the most Americans, restraining for providers and hospitals in fears of "dual fee schedule fraud" when giving patient "balance off-setting" discounts.

 

The new environment starting 2004 with higher deductible of $1,000 from true HDHP under HSA and non-HSA plans and HHS new Indigent Discount policy will set new records of disastrous medical inflation, totally contrary to what HSA is said to promise and what employers have dreamed.

 

 

Therefore, U.S. health care failure and crisis can be diagnosed as:

 

"ERISA Failure" = "Quality Failure" in U.S. Heath Care Crisis;

 

"Medical Inflation" = "Quantity Failure" in U.S. Health Care Crisis = Managed Care Contracting Discount and "Price Gouging".

 

"The history will prove that the headline political strategy and current trend in consumer-directed health plans and employee cost-sharing strategies will not be able to stop current US health-care crisis because these strategies and approaches are based on wrong diagnoses of current health-care crisis, without fundamental and etiology solution to the driving force of escalating and worsening health-care costs in billing and charges by health-care providers as a form of survival and revengeful but spiral billings as a result of reckless and noncompliant claim denials. These strategies are simply shifting crisis to the employees and federal government tax program to practically accelerate health costs by temporarily covering up the pain and suffering from the employers and by punishing the very victims of health-care and labor industry: American workers and their families as well as patients. The strategies, however, will alleviate temporarily the employers' pain and crisis in offering and sponsoring health health-care benefits. Without fundamentally fixing the driving force of current health-care escalating costs, and in case of next major failure from consumer-directed health plans and employee cost-sharing strategies, this nation will face and suffer from not only health-care crisis, but also labor crisis and national deficit crisis ($44 trillion deficit) from tax incentive sponsored, employee health benefits driven and health-care out-of-control infected disasters.

 

Wal-Mart bare-bones benefits strategy and Band-Aid fix and solutions to the U.S. healthcare and labor crisis will temporarily stop "local bleeding" (health care costs per employee 40% less than the U.S. average, Wysocki/Zimmerman, Wall Street Journal, 9/30) for no more than two years and will inevitably result in unintended backslash accelerating employer-sponsored health care benefits system collapsing and labor disasters.

 

Because Wal-Mart bare-bones benefits package discourages and precludes noncatastrophic medical claims but covers and "promotes" the catastrophic medical claims with no lifetime cap, that will practically quadruple the catastrophic medical claims in two years, with an upfront benefits saving by 40% and catastrophic benefits cost increase by 400% in the end.

 

Wal-Mart company spokeswoman Sarah Clark tells Connect that Wal-Mart's health plan does not cover employees' everyday health expenses like flu shots, eye exams and child vaccinations. Further, plan deductibles can reach as high as $1,000 and premiums have risen 50% over the past two years. However, the company does cover catastrophic medical claims, with no lifetime cap. According to Clark, who maintains employees prefer the plan design. "Generally, our associates are more concerned about the cost of the bimonthly premiums than they are about the inclusion of [traditional health expenses]," she explains. "Thus, we offer a strong catastrophic plan that is affordable to many, rather than a richer plan that is affordable to only a few."

 

However according to Aon Consulting, "What's Your Strategy for Controlling Health Care Costs?"(pdf): "27% individuals spend 85% dollars, 33% expenses for preventable conditions, 50-60% hospital admissions due to chronic conditions, This is where the money is! "(page 24)

 

Wal-Mart is nation's number one employer, if 33% of preventable conditions and 60% of hospital admissions become eligible for the catastrophic medical claims for another 27%, 54% of Wal-Mart Associates in two years, everyday low-price logo may not hold the truth.

 

Which Medical Conditions Account For the Rise In Health Care Spending? (Health Affairs)  [Article HTML Version] [Reprint (PDF)]

 

15 Illnesses Drive Up Costs (washingtonpost.com)

 

"As insurers, employers and average Americans grapple with skyrocketing health care bills, a study being published today has found that a small number of illnesses -- many of them preventable -- account for most of the spending increase over the past two decades.....

 

"In many other areas, though, Thorpe found that "we do a substandard job of providing care" or identifying why certain maladies are on the rise. Two of the biggest mysteries, he said, were the "explosion" in patients reporting back pain and pulmonary cases, such as asthma and allergies."

 

Employer's Next Surprises and Crisis

 

Nixon Peabody's August 2004 Benefits Briefs: Legal Developments for Employee Benefits (PDF) (Nixon Peabody LLP)

6 Pages, Excerpt: "Getting Burned by Ignoring People with “Colorable” Claims to Plan Participation

You surely know that plan participants and beneficiaries are entitled to receive copies of relevant plan documents, if they request them. You also should know that if you fail to provide requested documents within thirty days a court can impose a penalty of up to $110 per day for each day you are late. What if you turn down a request from someone who is not a participant or beneficiary but thinks he is? You could be in for a penalty if he has a “colorable” claim. Lowe v. McGraw-Hill, 361 F.3d 335 (7th Cir. Mar. 15, 2004)."

Tittle v. Enron Corp.
2003 U.S. Dist. LEXIS 17492 (S.D. Tex. 2003)]

entered October 1, 2003.
(pdf, 331 page document - may take up to 11 minutes to download.)

or

Text of Enron Memorandum and Order, Part I (PDF) (U.S. District Court for the Southern District of Texas)

 

Text of Enron Memorandum and Order, Part II (PDF) (U.S. District Court for the Southern District of Texas)

 

Text of Enron Memorandum and Order, Part III (PDF) (U.S. District Court for the Southern District of Texas)

Excerpt: "The above referenced action is brought on behalf of Enron Corporation ... employees who were participants in three employee pension benefit plans governed by [ERISA], specifically the Enron Corporation Savings Plan ... the Enron Corporation Employee Stock Ownership Plan ... and the Enron Corporation Cash Balance Plan ... and also on behalf of Enron employees who received 'phantom stock' as compensation."

 

Executive Summary – Enron ERISA Litigation Ruling (Groom Law Group)

Excerpt: "While the Court's ruling breaks little new ground, some of the more significant conclusions that it reached include: The individual officers and directors who act with respect to a benefit plan on behalf of a corporate fiduciary are themselves ERISA fiduciaries (disagreeing with the Third Circuit's ruling in Confer v. Custom Engineering Co., 952 F.3d 34, 37 (3rd Cir. 1991))."

 

Enron Case Moves Forward: Plan Fiduciaries Should Take Note (PDF) (Gardner Carton & Douglas)

 

Court Refuses to Dismiss Fiduciary Breach Claims in Enron Litigation (EBIA WEEKLY)

 

 

9/4/2003: Text of DOL Amicus Brief Supporting Money Damages Against Employer as Fiduciary in Life Ins. Case (U.S. Department of Labor, Office of the Solicitor)

Callery v. The United States Life Insurance Company in New York, No. 03-4097 (filed with 10th Cir. on Aug. 20, 2003).

 

Excerpt: "Star Buffet offered life insurance coverage to its employees through a policy issued by United States Life Insurance Company ... Callery was never provided with a summary plan description that outlined the life insurance policy's scope of coverage and exclusions, nor had the insurance policy itself been distributed to Callery or other Star Buffet employees."

9/4/2003: Text of DOL Amicus Brief on Claim Against Directors for Failing to Oversee Investment Committee (U.S. Department of Labor, Office of the Solicitor)

Excerpt: "The Complaint in this case alleges that the members of the Williams Company Board of Directors, who admittedly were charged with the duty to appoint, retain and remove members of the Benefits Committee, breached their fiduciary duties under ERISA by failing to monitor the Committee members and failing to provide them with the information that they needed to carry out their investment responsibilities."

 

Report of the ERISA Advisory Council's Working Group on Fiduciary Education and Training (U.S. Department of Labor, Employee Benefits Security Administration)

November 8, 2002. Excerpt: "[W]e heard from an extraordinary array of able and thoughtful individuals, some representing professional organizations and some speaking on their own behalf.... There were ... important differences in perspectives, but there was also a surprising amount of agreement on where education can help fiduciaries perform better. We strongly urge anyone interested in the issue of fiduciary education to read through the transcripts of our work group's hearings ..."

Employer Health Plan Nightmares ... and Other Things That Go Bump in the Night (Chang Ruthenberg & Long PC)

Excerpt: "[I]f you can identify the intended benefits, the intended beneficiaries (e.g., employees and their families), and a procedure to apply for and receive benefits, then you probably have one or more ERISA welfare plans. Your company's welfare plans may be 'wrapped' together as one plan, or the company may have multiple welfare plans. Even if the benefits are provided solely by insurance contracts, there is a good chance that the company is the sponsor of an ERISA welfare plan."

Medical Cost Reference Guide (BlueCross BlueShield Association)

Excerpt: "A key step to maintaining access to affordable healthcare is understanding the drivers of healthcare costs. To foster this understanding, BCBSA recently published the Medical Cost Reference Guide, a compendium of the best secondary research available focusing on the key drivers of healthcare costs."

HSAs Might Alter Group Health Coverage (Washington Post)

Excerpt: "A provision of the Medicare bill Congress passed this week would allow workers to turn a health insurance feature they normally dislike -- a high deductible -- into tax-free savings that could grow to large sums over a lifetime.... The provision could have a profound effect on employer-base medical insurance plans, some experts said."

Health Reform Losers, Winners (The Baltimore Sun)

Excerpt: "The $400 billion drug benefit Congress voted to add to Medicare is a brand-new entitlement for 40 million elderly and disabled people. But while some will do better with the new coverage, others will not. And some will likely do worse."

Union official urges health care reform-(Manitowoc Herald Times Reporter)

 

Op-Ed Contributor: The State of Health Care, in One Easy Number

 

Hewitt Study Shows Employers Critically Concerned with Health Care Costs and Looking for Creative Solutions

 

Hewitt Federal Legislation Quick Guide: June 15, 2004 (Hewitt)

 

Workers' health-care costs may continue rise (The Courier-Journal)

 

Health care costs shifting to employees, study finds (Rocky Mountain News)

 

Tracking Health Care Costs: Trends Slow in First Half of 2003 (Center for Studying Health System Change)

 

Health care costs continue double digit increase / Employees bearing more of the costs (Victoria Colliver, Chronicle Staff Writer )

 

Health Care Costs to Continue Climbing at Double-Digit Rates, According to Results of Latest Mellon Survey

 

Unknown Prices Hamper Health Care Reform Efforts (AP via Washington Post)

Excerpt: "Almost nobody, from the doctor to the patient, knows what a given procedure really costs. And that's a real problem for would-be reformers who favor a system that counts on consumers to hold down health care costs, by putting them in charge of their own spending."

'We thought we had insurance' (Sunday Gazette-Mail)

"Through most of 2002, they scrambled for help from their union and an array of state and federal agencies and elected officials. Nobody stopped the unfolding financial disaster. They were caught in a regulatory no-man’s land."

A High-Stakes Union Fight: Who Will Fold First? (Workforce.com)

 

The 2003 MetLife Study of Employee Benefits Trends (PDF) (MetLife)

 

Whose Problem Is Health Care? (New York Times)

"American companies have ingeniously managed to contain labor costs through productivity gains, outsourcing and limiting wages. But the factors over which manufacturers have less control - structural costs like those for corporate income taxes, employee benefits and rule compliance - have surged, according to a study released in December by two trade groups, the Manufacturers Alliance and the National Association of Manufacturers."

 

"After corporate income taxes, employee benefits are the second-largest structural cost for American manufacturers, adding 5.8 percent to costs, according to the study. In all major economies, paying for health care means a combination of public and private money. But in the United States, businesses pay a larger chunk than do their European and Asian counterparts."

 

"Uwe Reinhardt, an economist at Princeton, has referred to General Motors, Ford and Daimler-Chrysler as "a social insurance system that sells cars to finance itself.''

 

"Few business leaders advocate that government provide comprehensive health insurance for American workers not in Medicare - at least not yet. The National Association of Manufacturers would like the system to evolve from one in which employers provide benefits to one in which consumers buy health care."

 

Towers Perrin Legislative Tracking Chart as of Feb. 17, 2004: Health and Welfare Issues (PDF) (Towers Perrin)

Towers Perrin Legislative Tracking Chart as of Feb. 17, 2004: Retirement Issues (PDF) (Towers Perrin)

Towers Perrin Legislative Tracking Chart as of Feb. 17, 2004: Human Resources Issues (PDF) (Towers Perrin)

 

Opinion: Administration Proposal Could Weaken Employer-Based Health Insurance (PDF) (Center on Budget and Policy Priorities)

 

Soaring Health Care Costs Leave Little Companies in a Bind (New York Times)

 

USATODAY.com - Hospitals sock uninsured with much bigger bills

 

Binion's Targeted for Insurance Probe (casinocitytimes.com)

"LAS VEGAS -- Binion's Horseshoe and its owner, Becky Binion Behnen, are being investigated by the U.S. Department of Labor for possible violations of federal law involving $2.5 million in unpaid worker health insurance claims, officials said Friday."

"Pipal said there is little recourse for disgruntled physicians and their patients, because managed-care companies function under the Employee Retirement Income Security Act (ERISA) of 1974, a federal law with new provisions governing health care benefits."

California Grocery Workers Vote To Approve Contract, Ending Strike Over Changes To Health Benefits (KaiserNetwork.org)

 

Forbes.com: GM health-care costs rise despite Medicare change

GM's Future Retiree Health Obligations Total $60B, Even After Medicare Subsidies (KaiserNetwork.org)

GM says health care obligation hit $67.5 billion in 2003 (AP Wire | 03/11/2004)

"GM has said its total cash expense for health care is expected to climb to $5.1 billion this year from $4.8 billion in 2003. The bulk of the expense is for retiree benefits and prescription drugs.

Dubrowski said the expense saddles GM, Ford Motor Co. and DaimlerChrysler AG's Chrysler Group with liabilities many foreign rivals do not encounter.

 

"Before a car even leaves our factory it's got a $1,400 cost disadvantage relative to an overseas model," he said."

Judge ends health care coverage for 9,000 Weirton Steel retirees (Chicago Sun Times)

 

Fact Sheet: Affordable Health Care for America's Families (White House)

 

Bush makes fresh pitch for health care remedies, tax cuts (AP through San Francisco Chronicle)

 

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."

Opinion: HSA Rules from IRS Are Good Guidance (The Galen Institute)

 

Health Savings Accounts Ready To Enter the Market (Managed Care Magazine)

 

Health Insurers See New Role Managing Information

 

Hewitt Study Shows Majority of Employers Likely to Offer New Health Savings Accounts

 

Employers' Contradictory Views About Consumer-Driven Health Care (Health Affairs)

 

Trends and Indicators in the Changing Health Care Marketplace, 2004 Update (The Henry J. Kaiser Family Foundation)

Excerpt: "Trends and Indicators in the Changing Health Care Marketplace, 2004 Update (April 2004) presents information on key trends in the health care marketplace of interest to policymakers, public interest groups, the media, and industry analysts and leaders.' Click on any of the 'sections' listed in the right-hand menu bar on the target page.

DOJ Sues Promoters of Schemes to Report Lower Taxes Using Sham Health Care Reimbursements (Employee Benefits Institute of America Inc. (EBIA))

 

Evolving Role of Third Party Administrators Brings New Demands and Innovations (Employee Benefit News)

Excerpt: "Gone are the days of third party administrators (TPAs) simply processing claims and cutting checks for Taft-Hartley plans. Today's TPAs are assisting their clients in everything from creating new benefit plan models to contain costs and boost worker recruitment and retention to providing the latest and greatest regulatory compliance counsel."

Staying Out of Jail Under ERISA's Bulked-Up Criminal Law Penalites (Attorneys Russell D. Shurtz and Craig R. Pett)

Excerpt:

 

"Criminal Sanctions Under ERISA Section 501

 

Maximum Criminal
Fine (Individuals)

Maximum Jail
Time

Maximum Criminal
Fine (Companies)

Before Sarbanes-Oxley

    $5,000

One Year

$100,000

After Sarbanes-Oxley

$100,000

Ten Years

$500,000"

"These are hefty increases. Few have focused on the fact that these bolstered penalties apply not only to black-out notices, but also to ERISA's other plain-vanilla reporting and disclosure requirements. The term "criminal penalties" seems so out of place with mundane things like SPDs, SARs, and other run-of-the-mill benefit plan documents."

What Sites Do You Visit To Keep Up with Employee Benefits Compliance and Design Developments? (BenefitsLink Wiki)

 

Bureau of Justice Statistics Medical Malpractice Trials and Verdicts in Large Counties, 2001  (Acrobat file) (Press release)

 

Incidence Benefits Measures in the 2003 National Compensation Survey (U.S. Department of Labor, Bureau of Labor Statistics)

 

New Statistics for Health Insurance from the 2003 National Compensation Survey (U.S. Department of Labor, Bureau of Labor Statistics)

 

Trends In Employer-Provided Prescription-Drug Coverage (U.S. Department of Labor, Bureau of Labor Statistics)

 

Medical and Retirement Plan Coverage: Exploring the Decline in Recent Years (U.S. Department of Labor, Bureau of Labor Statistics)

 

New Benefits Data from the 2003 National Compensation Survey (U.S. Department of Labor, Bureau of Labor Statistics)

 

The 2003 National Compensation Survey: a Wealth of Benefits Data (U.S. Department of Labor, Bureau of Labor Statistics)

 



HEALTH COSTS--The Breaking Point (FORTUNE.com)

Excerpt: "Worker health costs will rise a staggering 24% this year. Companies can no longer afford to pick up the bill. The battle is here."

Healthcare Costs Are Key Issue in Big 3 Automakers' Union Negotations (USA Today)

 

State Health Plans Cover More Workers Than Private Plans But Suffer the Same Cost Problems (Spencer Benefits Reports)

 

Health Care Costs To Continue To Climb At Double-Digit Rates In 2004 (Spencer Benefits Reports)

 

Health Care Costs Still Climbing at Double-Digit Rates, According to Results of Buck Consultants Survey (Mellon Financial Corporation)

 

2003 Employer Health Benefits Survey (The Henry J. Kaiser Family Foundation)

 

Employees Paying Ever-Bigger Share for Health Care (New York Times; one-time registration required)

 

California Bill for Employer-Paid Health Coverage to be Expensive, and Might Be Preempted by ERISA (San Francisco Chronicle via International Foundation of Employee Benefit Plans)

 

Overview: Pay or Play in California? (PDF) (Seyfarth Shaw LLP)

 

Opinion: Detroit's Healthcare Crisis-- and Ours (Geoffrey Colvin on Fortune.com)

 

UAW Made Concessions on Wage Increases To Preserve Health Benefits (KaiserNetwork.org)

 

GAO: Common Standards and Improved Coordination Needed for Insurance Regulation (U.S. General Accounting Office)

53 pages. Excerpt: "Market conduct regulation--oversight of insurance company practices such as selling and underwriting policies--is the responsibility of the same state agencies that oversee insurance companies' financial solvency. Unlike financial regulation, however, with its nationwide standards that allow for coordination among state regulators, no generally accepted standards exist for market conduct regulation.' Summary at http://www.gao.gov/highlights/d03433high.pdf

 

GAO Report: Health Insurance-- Federal and State Laws Affecting Coverage by Small Businesses (U.S. General Accounting Office)

63 pages. Excerpt: "GAO was asked to summarize current federal and state requirements for health coverage offered by small businesses, including mandated benefits, premium-setting requirements, and requirements regarding availability of coverage.' Summary at http://www.gao.gov/highlights/d031133high.pdf

New proponents of overhaul for healthcare: CEOs (Christian Science Monitor, June 05, 2003)

Excerpt: "In an extraordinary gathering, the CEOs of some of America's largest companies - from Kellogg's to SBC Communications - called on Congress and the White House to stop dillydallying with band-aids for the nation's healthcare system and to come up with comprehensive, systematic reform."
 

CEO: Let’s Fix Health Care (Portsmouth Herald, NH - May 2, 2003)

Excerpt: "If there is to be reform of health care, it must be done by the business community, said Fisher Scientific International Chairman and Chief Executive Officer Paul Montrone Thursday at the University of New Hampshire’s CEO Forum.

Ford: Rising Health Care Costs a Problem (AP)

Excerpt: "Ford told the Detroit Regional Chamber's annual Leadership Policy Conference that the rising prices of health benefits is the "biggest issue on our plate that we can't solve."

 

"Health care is just out of control," he said. "It's a system that's broken. It really scares me enormously."

Employers Looking for More Help with Cost Reduction from Health Insurers, Third-Party Administrators (PLANSPONSOR.com; one-time registration required)

Excerpt: "Roughly three-quarters (73%) of employers say their health plans are not meeting expectations in terms of reducing insurance costs, and nearly two-thirds (64%) of employer respondents to a new survey say that current efforts being made by health plans are ineffective in reducing costs, according to a report from competitive intelligence firm Provizio."

Healthcare Cost Spiral Seen Continuing (Health - Reuters via Yahoo)

Excerpt:  "Despite concern about long-term cost trends, there seems to be little consensus about how to control overall healthcare spending while preserving access to high-quality care.

 

"There's really not very much cost-control going on at all other than employers moving to cost-sharing," Cassil noted."

Restaurateur Considers Tabling Health Benefits for Employees (Inc. Magazine)

Excerpt: "Prentice, president and owner of Unique Restaurant Corporation, has become Detroit's peerless culinary celebrity in part by attracting the best managers, waiters, busboys, and bartenders to work for him. The company, with $40 million in annual revenue, attracts such talent by providing excellent benefits. But with the auto industry slumping and health care costs soaring, Prentice recently found himself considering the once unthinkable: dropping employee health care coverage."

Healthcare, Heal Thyself (CFO.com)

Excerpt: "Consumer-directed health care is hot. But is it a danger to the medical-insurance system?"

Trends in the Health Insurance Marketplace (PDF) (The Galen Institute)

 

Employers' Health Costs Expected To Rise 12% Next Year, New Survey Says (KaiserNetwork.org)

 

Towers Perrin Projects Fifth Consecutive Year of Double-Digit Health Care Cost Increases in 2004

 

Census Bureau release: Numbers of Americans With and Without Health Insurance Rise

 

ajc.com | News | 15.2% in U.S. are uninsured

15.2% in U.S. are uninsured
High costs, job losses push number with no health coverage to 43.6 million

 

 

Survey: Americans More Worried About Healthcare Costs Than Terrorist Attacks (The Henry J. Kaiser Family Foundation)

Excerpt: "We were surprised to find in our latest tracking poll that more Americans are worried about health care costs than about losing their job, paying their rent or mortgage, losing money in the stock market, or being a victim of a terrorist attack.

 

Nearly four in 10 Americans (38%) say they are very worried that the amount they pay for health care services or health insurance will increase, and a similar share (37%) is very worried that their income might not keep up with rising prices over the next six months."

Thousands of Former Bethlehem Steel Employees Scramble for Health Coverage (The [Philadelphia] Inquirer)

Excerpt: "More than 200,000 retired steelworkers and their dependents-- including 95,000 from Bethlehem Steel and its Lukens division-- have lost health-insurance coverage in recent years, as 37 steelmakers have gone into Chapter 11. Union leaders say it is just a matter of time before retirees in other industries-- such as airlines-- are faced with the same experience."

United Auto Workers Chief Says National Healthcare Program Required (Detroit Free Press)

Excerpt: "The head of the United Auto Workers put automakers on notice Monday: You can't stem rising health-care costs by shifting the burden to workers and retirees. The auto industry alone can't solve "America's health care crisis."

Opinion: The Coming Crash in Health Care (Fortune.com)

"Thus it may come as a surprise to learn that the managed-care industry is dying. Oops, did we spill the beans so soon? Well, so be it. Managed care is on the way out."

Opinion: An Overview of the Troubling Medicare Legislation (Center for Budget and Policy Priorities)

 

Shifting Burden Helps Employers Lower Rate of Health Cost Increase (Dow Jones Business News via Yahoo! News)

 

Health Care Tops Taxes As Small Business Cost Drain (USA Today)

Excerpt: "For the first time in nearly 20 years, small businesses say soaring worker health costs, not taxes, are their biggest headache. Taxes had been No. 1 since 1986."

Employees Do Not Feel Responsible For Higher Health Care Costs: Survey (Spencer Benefit Reports)

Excerpt: "Employees disagree with their employers about employees' responsibility to help restrain rising health care costs, according to a survey recently released by Towers Perrin. The national survey, Keeping Employees Engaged About Health Care, was conducted in February 2003 with individuals working for an employer with at least 1,000 employees and with employer-sponsored health care benefits.

An Employer's Guide to Patient-Directed Healthcare (65-page PDF book) (Wye River Group on Healthcare)

 

Overview: IRS Issues Guidance for New Health Reimbursement Arrangements (Watson Wyatt)

 

Analysis: Debit/Credit Card Medical FSA and HRA Reimbursements (PDF) (Milliman USA)

 

Federal Government Trying to Get Flexible On Employees' Spending (Washington Post via International Foundation of Employee Benefit Plans)
 

Consumers Take Charge: Defined-Contribution Health Plans (PDF) (The Wharton School of the University of Pennsylvania)

8 pages. Excerpt: "The goal is to temper rising costs and improve service quality by giving consumers better information and greater control over how they spend their health-care dollars. Defined-contribution plans won't replace managed care plans, but they will be the next dominant form."

Consumerism in Health Care: the Quest to Create New Partnerships for Responsibility and Accountability (PDF) (The Segal Company)

 

Aon Health Care Survey 2003 (pdf)

 

Harris Survey on Health Benefit Trends in California (California Health Care Foundation)

 

IRS Modifies HSA Eligibility Rule for 2004, 2005 for Individuals Covered by Prescription Drug Plan (PDF) (Internal Revenue Service)

 

Rev. Rul. 2004-38 Clarifies HSA Eligibility Rule for Individuals Covered by Prescription Drug Plans (PDF) (Internal Revenue Service)

 

IRS Provides Safe Harbor for Preventive Care Benefits Under High-Deductible Health Plan (PDF) (Internal Revenue Service)

 

HSAs Established Before April 15, 2005 Can Cover Expenses Incurred On or After January 1, 2004 (PDF) (Internal Revenue Service)

 

Frequently Asked Questions About Health Savings Accounts (HSAs) (U.S. Treasury Department)

 

Draft Form Issued by IRS: Model Health Savings Account for Use by Trustees (PDF) (Internal Revenue Service)

 

Draft Form Issued by IRS: Model Health Savings Account for Use by Custodians (PDF) (Internal Revenue Service)

 

 

 

"Workers more negative on health care
Survey: 51% reject cost-sharing as appropriate measure"

Employee Opposition to Cost-Shifting Grows (Business Insurance)

 

Differences Among HRAs, HSAs and FSAs-- Beyond the Basics (Attorneys Greta Cowart of Haynes & Boone LLP and T. David Cowart of Jenkens & Gilchrist)

CHOOSING A NEW HEALTH PLAN DESIGN?

DIFFERENCES AMONG HRAs, HSAs AND FSAs

BEYOND THE BASICS AND AFTER THE

FIRST WAVES OF GUIDANCE

American Health Lawyers Association Annual Meeting

"The Hunt for Red ERISA: Essential Concerns"

New York, NY

June 30, 2004

 

Text of Notice 2004-50 Providing 88 Q&As on Health Savings Accounts (PDF) (Internal Revenue Service)

 

Text of Notice 2004-50 Providing 88 Q&As on Health Savings Accounts (PDF) (Internal Revenue Service) (Revised and corrected--Aug. 9, 2004)  32 pages

 

Text of Proposed Regs for Medicare Prescription Drug Benefit (PDF)
233 pages. (Centers for Medicare & Medicaid Services, Department of Health and Human Services)

 

ERIC Summary Outline for Employer Sections (Title 1; J & R) of the Medicare Regulations (ERISA Industry Committee)

 

2004 Plan Year-End Planning Checklist for Advisors, Employer/Plan Sponsors and Fiduciaries (Milberg Consulting LLC)

With Doctors Envisions Altered Managed Care (New York Times)

Excerpt: "It also plans changes in a number of practices, like claims processing, that the doctors and the insurance company said would be worth about $300 million in savings for the doctors and the company. But Aetna said the changes would add only modestly to its costs because they were part of planned improvements in efficiency already under way."

 

"Dr. Rowe said the agreement should lead to lower costs for both the company and doctors. It will reduce doctors' overhead costs, he said, and Aetna will no longer be spending roughly $40 million a year on the legal costs related to the nationwide suit."

ERISA Demystified

1.     ERISA regulates up to 80% of health-care claims or 60% of health expenditures in the U. S. ($1.55 trillion in 2002), and has never been understood by health-care executives;

2.     American employers, plan sponsors and health-care executives have never been practically and meaningfully advised on ERISA education and strategy that covers ERISA statutes, regulations, case laws, claim procedure and dispute as well as health-care bottom-line: reimbursement under current managed care/ERISA environment;

3.     Health-care claim denial problems have fundamentally threatened health-care providers business survival;

4.     Up to 1/3 health-care claims was completely denied, rest of them partially and significantly denied.  Up to $600 billion claims were denied health-care claims in 2000.  Physicians Are at Breaking Point in heir Business Survival As a Result of the Managed Care Nightmare and Claims Denials under ERISA Shield

5.     $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

6.     Health insurance premium increased 14%-20% this year and almost every major health insurers are cutting jobs to cope with crisis;

7.     New trend in health-care funding and insurance from MSA, FSA, DCP as tax incentives to employee high premium and high deductible might fundamentally change U.S. health-care platforms;

8.     State law legislations (Prompt Pay and Patient Rights) have proven to be little or no protection (80% of ERISA claims); Patient Bill Of Rights, a revision of ERISA, will not provide any meaningful protection to health-care providers unless health-care executives really understand ERISA and its practical implementation in managed care environment, something remains to be mystery in reality and miracle in legislation;

9.     ERISA has been around for 28 years without any Executive 101 Briefing while ERISA relentlessly regulates 80 percent of U.S. health-care costs;

10.  New Federal Claim Procedure, to be effective January 2002, has been a monopoly for insurance/benefits executives but practically immune or allergic to health-care executives while it 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;

11.  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;

12.  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.

13.  Traditional Coding and Billing, documentation and electronic claim submission implementations have been proven marginal successful while many hospital’s reimbursement rate are well below 50%-25% across the country.

How Private Health Insurance Works: a Primer
 (Henry J. Kaiser Family Foundation)
Report 

 

Excerpt: "This primer ... examines the structure and operation of private health insurance-- including the types of organizations that provide it, how managed care is delivered, and how risk pools work-- and describes how private health insurance coverage is regulated under state and federal laws. The primer explains how the current nature of private insurance relates to key issues facing federal and state policymakers."

 

NAIC Members Adopt Discretionary Clause Model Act

Excerpt: "Model Helps Ensure Consumer Health Insurance Claims are Subject to a Fair Review

 

PHILADELPHIA (June 9, 2002) — Members of the National Association of Insurance Commissioners (NAIC) today adopted the Discretionary Clause Model Act at the association’s Summer National Meeting here.

 

The act, which was developed by the NAIC’s ERISA Working Group, prohibits the use of discretionary clauses in health insurance contracts.

 

“Discretionary clauses are an effort to give an insurance company full and final discretion in interpreting benefits and administering an insurance contract,” said Maryland Insurance Commissioner Steve Larsen, who chairs the Health Insurance and Managed Care Committee. “This places consumers at a significant disadvantage when they are seeking to overturn the denial of benefits under an insurance policy.”...."

 


 

NAIC: UTILIZATION REVIEW AND
BENEFIT DETERMINATION MODEL ACT  PDF file

 

Consumer Protections under ERISA and California Law Compared
 (California HealthCare Foundation)

 

Excerpt: "ERISA prevents states from directly regulating health insurance arrangements established by employers, but allows states to regulate the indemnity insurers and health plans with which employers contract.... [C]onsumer protections vary depending upon whether an employer decides to retain the risk of paying medical claims (that is, to 'self-insure' the employee plan) or to purchase group insurance from a state-licensed insurer or managed care organization."

 

Document Downloads from CHCF.ORG

ERISA and Variation in California Health Plan Consumer Protections (234K)pdf
Regulation of ERISA Plans: The Interplay of ERISA and California Law (534K)pdf

Few California Residents, Providers Aware of Law on Independent Review of Health Plan Decisions (KaiserNetwork.org)

 

Excerpt: "Many managed care patients and physicians in California are unaware of a state program that allows patients to appeal the decisions of their health plans, according to a report issued last week by the California HealthCare Foundation, the Los Angeles Times reports."

 

"The report recommended that the state DMHC develop a "how to" guide about the independent review program and distribute the guide in physician offices and employer human resource departments to increase participation. The report also recommended a campaign to explain the program to physicians and establish a system to ensure that health plans implement the decisions of the independent review board "in a timely manner," the Times reports."

 

Independent Medical Review Experiences in California (California HealthCare Foundation)

 

Independent Medical Review, Phase I (369K)Download Now

Independent Medical Review, Phase II (832K)Download Now

 

Excerpt: "This section of EBRI's Web site is designed to answer basic questions about major benefit issues and trends. It provides short, graphical answers, with links to the detailed data underlying the figure. In addition, references are provided to the relevant EBRI publication."

Employers' Benefits from Workers' Health Insurance  (Ellen O'Brien of Georgetown University, in The Milbank Quarterly)
(Featured article -- click here for full text)

 

The Struggle over Employee Benefits: The Role of Labor in Influencing Modern Health Policy
(David Rosner and Gerald Markowitz,
in The Milbank Quarterly)

 

O'Neill: Health costs can be halved  (post-gazette.com)

 

How Health Savings Accounts Compare To FSAs and HRAs (Groom Law Group)

 

Overview of the New Medicare Law (PDF) (Hewitt)

 

Return to cms.hhs.gov Home  
Return to cms.hhs.gov Home
Column 1/Column 2 Correct Coding Edits
(formerly Comprehensive/Component Edits)

 

Mutually Exclusive Edits

NCCI Policy Manual for Part B Medicare Carriers
Medicare Claims Processing Manual (Sec. 20.9)
NCCI Questions and Answers
NCCI Edits Program Transmittals

National Correct Coding Edits for the Hospital Outpatient PPS - Version 10.1
 (Effective April 1, 2004 - June 30, 2004)

Column 1/Column 2 Correct Coding Edits
(formerly Comprehensive/Component Edits)

Mutually Exclusive Edits

Comprehensive Error Rate Testing (CERT) Program FY 2003 IMPROPER MEDICARE FEE-FOR-SERVICE PAYMENTS REPORT (Short Version) (PDF 671 KB)
AMNews: Oct. 20, 2003. HHS inspectors' action plan reveals hot buttons for fraud ... American Medical News AMNews: Dec. 8, 2003. Primary care troubled by coding errors ... American Medical News
White Paper: Health Care Fraud-- a Serious and Costly Reality for All Americans (PDF) (National Health Care Anti-Fraud Association - www.nhcaa.org)

"Aetna and CIGNA Settlement Secrets"
"Talking Points"

 

FALLICK v NATIONWIDE MUTL INS

Usual, Customary and Reasonable Charges (UCR)

 

Text of IRS Notice 2004-2: Guidance on Health Savings Accounts (PDF) (Internal Revenue Service)

13 pages. Excerpt: "This notice provides certain basic information about HSAs in question and answer format, without attempting to enumerate all of the specific rules that apply under section 223. The notice is divided into five parts. Part I of the notice explains what HSAs are and who can have them. Part II describes how HSAs can be established. Parts III and IV cover contributions to HSAs and distributions from HSAs. Part V discusses other matters relating to HSAs."

 

 

 

Health Care Continuation Coverage; Final Rule [Rules and Regulations] [05/26/2004] | [PDF Version]| [Notices] | [Press Release]

 

DOL Health Benefits Education Campaign [New  Seminars: IL, NY, KY]

DOL Launches National Education Campaign "Getting It Right-Know Your Fiduciary Responsibilities"

 

Press Release  EBSA News Release: [05/18/2004]

Seminars are scheduled for Florida, Ohio, Massachusetts and Arizona, beginning in June 2004. The program will emphasize the obligation of plan sponsors and other fiduciaries to:

  • Understand the terms of their plans;

  • Select and monitor service providers carefully;

  • Make timely contributions to fund benefits;

  • Avoid prohibited transactions; and

  • Make timely disclosures to workers and their beneficiaries and reports to the government.

Publications

Meeting Your Fiduciary Responsibilities

Understanding Retirement Plan Fees And Expenses

Selecting An Auditor For Your Employee Benefit Plan

Reporting and Disclosure Guide for Employee Benefit Plans

 

 

Statutes (United States Code) 
ERISA - Title 29, Chapter 18. 

        Selected links:

Sec. 1002.
Definitions

Sec. 1003.
Coverage

Sec. 1022.
Summary plan description
Sec. 1104.
Fiduciary duties

Sec. 1140.
Interference with protected rights

Sec. 1141.
Coercive interference

part 7
group health plan requirements

 

 

Code of Federal Regulations

Codified in Title 29 of the Code of Federal Regulations:

Regulations

        Selected links:

2520.102-3 Contents of summary plan description.
2560.503-1 

Claims procedure.

 

 

Uninsured Reached

45 Million in 2003
US Census Press Releases

"The number of people with health insurance increased by 1.0 million to 243.3 million between 2002 and 2003, and the number without such coverage rose by 1.4 million to 45.0 million."

 

Income, Poverty, and Health Insurance Coverage in the United States: 2003 (P60-226) new
 

Health Insurance Data (Source: U.S. Census Bureau)

(10 years on the web)


Benefits cost cited in US hiring slump
Washington Times, DC - Aug 19, 2004

 

Revised November 2004 -- National Compensation Survey: Employee Benefits in U.S. Private Industry (PDF) (U.S. Department of Labor, Bureau of Labor Statistics)

 

Summary: National Compensation Survey: Employee Benefits in U.S. Private Industry, 2004 (PDF) (U.S. Bureau of Labor Statistics)

 

 

 

ERISA Laws/Rules

ERISA in the United States Code: Cross-reference table, table of contents

 

ERISA in US CODE

 

DOL Compliance Assistance for Health Plans

 

 

 

HHS Press Release:
 

2004.02.19: Text of Letter From Tommy G. Thompson Secretary of Health and Human Services To Richard J. Davidson, President, American Hospital Association.  

HHS FAQ "Questions On Charges For The Uninsured" (PDF)

HHS FAQ's "regarding offering discounts to the uninsured" (PDF)

 

OIG "HOSPITAL DISCOUNTS OFFERED TO PATIENTS WHO CANNOT AFFORD TO PAY THEIR HOSPITAL BILLS"



National Correct Coding Initiative Edits - Version 11
 

National Correct Coding Edits for the Hospital Outpatient PPS - Version 10.3


2003 Improper Medicare Fee-for-Service Payments Report

 

CMS Announces Revisions to Payment for Drugs and Physician Fee Schedule Payments for Calendar Year 2004

 

Medicare Announces 2004 Physician Fee Schedule and Payment Policy Changes

CMS Files for Download for Medicare Payment Systems

 

CMS Finalizes Appeals Process for Medicare Coverage Decisions

 

2003.12.10: HHS Announces Immediate Steps to Make Medicare-Approved Drug Discount Card Programs Available Next Spring

 

42 CFR Parts 403 and 408
Medicare Program; Medicare Prescription
Drug Discount Card; Interim Rule and Notice (pdf) (89 pages)

 

Revision of Billing Instructions for Purchased Services
 

Regional Offices Link


2004 Medicare Payment Information Available from CD-Rom (WPS, WI,MI,IL, MN)

 

 

 

New HIPAA Privacy and ERISA Claims Review Rules: 10 Reasons To Comply (Brown Rudnick Berlack Israels L.L.P.)
 

Group Health Plan Compliance with ERISA and HIPAA: Navigating the Legal and Administrative Maze (PDF) (Brown Rudnick Berlack Israels L.L.P.)

72 pages. A 'Question and Answer Resource Guide."

 

 

Report of the ERISA Advisory Council's Working Group on Fiduciary Education and Training (U.S. Department of Labor, Employee Benefits Security Administration)

Excerpt: "We strongly urge anyone interested in the issue of fiduciary education to read through the transcripts of our work group's hearings ..."

 

 

Medical Cost Reference Guide (BlueCross BlueShield Association)

The Battle Over Benefits (Workforce.com)

CEO: Let’s Fix Health Care (Portsmouth Herald, NH)

 

Talk About Health Care: Sorry, Wrong Numbers (washingtonpost.com) by M. Gregg Bloche (Washington Post)

Excerpt: "Health care is back on the national agenda, and Democrats and Republicans alike are acting on a dangerously flawed premise. They are offering big plans that are based on the outdated assumption that managed care can control medical costs."

 

Read Making a Killing

 

 

 

 

 

Strangers in the Night: Law and Medicine in the Managed Care Era
by Peter D. Jacobson

J.D., M.P.H.
Associate Professor.
Department of Health Management & Policy
.
School of Public Health.
University of Michigan.

(Summary by Author)
 

Book Reviews: Strangers In The Night: Law And Medicine In The Managed Care Era

by M. Gregg Bloche

(healthaffairs.org)

 

The Failed Jurisprudence of Managed Care, and How to Fix It (pdf)

Abstract

RUSSELL B. KOROBKIN
University of California, Los Angeles - School of Law

 

Law As An Agent of Health System Change

 - [Abstract]
[Full Text] [PDF]

(Health Affairs)

 

Aetna Reaches Agreement with Physicians, May 22, 2003 (Aetna.com)

 

Aetna Agreement With Doctors Envisions Altered Managed Care (New York Times)

"It also plans changes in a number of practices, like claims processing, that the doctors and the insurance company said would be worth about $300 million in savings for the doctors and the company. But Aetna said the changes would add only modestly to its costs because they were part of planned improvements in efficiency already under way."

"Dr. Rowe said the agreement should lead to lower costs for both the company and doctors. It will reduce doctors' overhead costs, he said, and Aetna will no longer be spending roughly $40 million a year on the legal costs related to the nationwide suit."

 

Aetna Agreement Could Affect Health Plan Administrators (The National Underwriter Company via International Foundation of Employee Benefit Plans)

 

Health Care Cost and Access Problems Intensify (Center for Studying Health System Change)

 

What's Your Strategy for Controlling Healthcare Costs? (PDF) (Aon Consulting/Radford Surveys)

 

KFF State Health Facts Online

 

CFO.com - Ill Wind: The Health-Benefits Crisis

 

ERISA Not Insurance

Aetna Video Shows ERISA Patients Mistreated

 

"According to the video, when faced with claims for identical medical problems, Aetna separates the claims where no damages are available - those subject to the federal Employee Retirement Income Security Act, or ERISA - from non-ERISA claims, where consumers can sue.1 2"

 

Aetna ERISA Settlemnt with 950,000 MD's

 

 

Business Health Care Group at 43 members (Milwaukee Journal Sentinel)

 

 

 

 

One Employee, One Shareholder, But ERISA Plan

(Name of the Game for 80 Percent of Health-care Claims in U.S.)

Gilbert v. Alta Health & Life Insurance Co. (11th Cir. No. 01-10829,12/27/01).

 

NHPF Publications  

 

NHPF Publications  

 

NHPF Publications  

 

 

 

 

2003 Segal Health Plan Cost Trend Survey: Preliminary Findings (PDF) (The Segal Company)

 

Tiered Hospital Plans (07/29/2003) (

 

Tiered Networks for Hospital and Physician Health Care Services (Employee Benefit Research Institute)

 

Retiree Health Care Benefits: Data Collection Issues (07/29/2003)

 

Facts from EBRI: Health Insurance and the Elderly (PDF) (Employee Benefit Research Institute)

 

Excerpt: "In 2001, 32.2 percent of the elderly had employment-based health insurance coverage in addition to Medicare, up from 28.7 percent in 1987." (page 2)

 

Blue Cross And Blue Shield System's Anti-Fraud Efforts Saved $157 Million

 

 

DOL Secretary Testifies to Committee About ERISA Enforcement, Compliance Assistance (U.S. Department of Labor, Pension and Welfare Benefits Administration)

 

 

Study: Health Insurance Premiums Rose More Than 30 Percent Between 1996 and 2000 (U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality)

 

 

 

 

 

 

Opinion: Cutting Costs in Half Through Better Management is Fantasy But Health Care Debate Is Real (The Hartford Courant)
Excerpt: "If a talk on economics can have a $650 billion throwaway line, Treasury Secretary Paul O'Neill delivered it.... "

 

"O'Neill insists the problem is not with people, but systems - systems that invite medical errors, systems that penalize health care professionals for making honest mistakes, systems that create the mind-numbing complexity of reimbursement for providers, systems that reward too much treatment and punish efficiency."

 

ctnow.com

 Health Cost Trends Shift

"The study said managed care probably has squeezed out all the savings it can from the nation's health care system and that employers are turning to other familiar devices such as increasing premiums and co-payments to trim their costs"

 

Op-Ed Contributor: The State of Health Care, in One Easy Number

 

 

Independent Medical Review Experiences in California (California HealthCare Foundation)

 

 

Health Care Issues Stymie Congress (The Hartford Courant)

 

 

 

 

 

 

Kinder and Gentler: Physicians and Managed Care, 1997-2001 (Center for Studying Health System Change)

 

 

 

Office for Civil Rights - HIPAA

OCR Guidance Explaining Significant Aspects of the Privacy Rule- December 4, 2002

 

New Federal Credit Law Restricts Employers' Use of Employee Medical Information (Thompson Publishing Group)

 

AMNews through  AMA

Health plans subject to new federal appeals rules
Much-postponed regulations offer patients and doctors fairer and faster review, plus new rights, Dept. of Labor says.

 

 

Health Care Spending Rose 8.7% in 2001, the Fastest Rate in 10 Years, Government Statistics Say (KaiserNetwork.org)

 

 

Norwood Introduces The Patient Protection & ERISA Clarification Acts

 

Managed Care and Patients' Rights
(JAMA Editorial)


Enrollee Appeals of Preservice Coverage Denials at 2 Health Maintenance Organizations (JAMA Abstract)

 

Managing Care: Utilization Review In Action At Two Capitated Medical Groups (Health Affairs)

"We found much higher denial rates than those previously reported."


 

 

Employer Health Benefits: 2002 Annual Survey.(pdf)
Accessibility verified January 30, 2003
(KaiserNetwork.org)

 

 

New BCBSA Report Shows Health Insurer Administrative Costs Rising Slower Than Premiums; Identifies Key Cost-Drivers (U.S.Newswire, 2/21/2003)

"Milliman studied national health insurance administrative cost trends from 1998 to 2002 and found that while premiums for commercial business increased by an average of 7.4 percent annually, administrative costs grew at a much slower average rate of 4.6 percent annually. The report shows that in 2001, an average of 85.7 percent of commercial premiums went to pay medical claims with 11.6 percent going to administrative costs and 2.7 percent going to profits. In comparison, an average of 86.5 percent of commercial premiums among Blue Cross and Blue Shield Plans went to medical claims in 2001, with 11 percent going to administrative costs and 2.5 percent going to profits."

 

 

New BCBSA Report Shows Health Insurer Administrative Costs Rising Slower Than Premiums (BCBSA)
 

Health Plan Administrative Cost Trends (Milliman USA) 02/20/2003

"we conclude that an increased focus in delivering customer service and an increased investment in information technology to meet the requirements of Y2K and the Health Insurance Portability and Accountability Act of 1996

(HIPAA), has driven cost increases during the past five years."

 

Trends in the Health Insurance Marketplace (PDF) (The Galen Institute)

 

 

BlueCard Delivers National Clients, Admin. Revenues for Blues Plans

 

NASCO Works With Blues Plans To Increase Large Local Accounts

Welcome To NASCO

 

Two Blues Giants' Enrollment Gains Show More Americans Are Turning Blue

 

Most Blue Cross Blue Shield Plans Predict Significant Managed Care Growth in 2003

 

Google Search: Bluecard program Fiduciary

 

Google Search: Bluecard program ASO

 

Google Search: Bluecard program SECURITIES AND EXCHANGE COMMISSION

 

BCBS GROUP ENROLLMENT & COVERAGE AGREEMENT

 

WellChoice 10K SEC

View as HTML

WellChoice 10-K Form

 

Anthem & WELLPOINT
Larry Glasscock, Chairman, President and CEO (PDF)

Investor Presentation

View as HTML

 

Summary of ANTHEM INC - Yahoo! Finance

 

Summary of WELLCHOICE INC - Yahoo! Finance

 

US AIRWAYS SPD

 

Blue Cross Blue Shield of Michigan United of Omaha Major Medical for UM

 

BCBSMT PPO Manual
View as HTML

 

BCBSTX UT SPD

View as HTML

 

BlueCard PPO BCBS

 

tdi.state.tx.us

ERISA vs Non-ERISA Identification on cards (pdf)   View as HTML

 

Table of Contents - Health Care Benefits Law - LawCatalog.com

 

 

University faces $2M in health care debt

"Nowak said a big part of the medical care issue is education for all people affected by it, which is a top priority of the HCC."

 

 

Cash-poor UCLA hospitals hire turnaround firm  (Los Angeles Times)
"Turnaround firm is asked to increase efficiency and cut costs for the system, which fiscally lags far behind its UC counterparts."

 

"The largest medical system in the UC chain, UCLA Healthcare reported lower net income than its sister campuses last fiscal year and as of Dec. 31 had only $20,000 cash. By comparison, UC Davis had $183 million in cash, the most systemwide."

"Now, the campus is paying more than $1.9 million for health-care consultants to look for ways to cut costs and improve efficiency."

 

Cuts Urged for UCLA Health Staff (LATIMES.com)

 

"The Hunter Group, a consulting firm paid $1.9 million by UCLA to suggest reforms, also said billing practices need revamping. They are so haphazard that the system billed 300 different amounts for the same procedure."

 

 

National Compensation Survey: Employee Benefits in Private Industry in the United States, 2000 (PDF) (U.S. Department of Labor, Bureau of Labor Statistics)

 

Government Survey: Employee Benefits in Private Industry, 2003 (U.S. Department of Labor, Bureau of Labor Statistics)

 

 

Data Provide Details on Characteristics of Health Insurance of U.S. Workers (Agency for Healthcare Research and Quality)

 

 

Opinion: The Coming Crash in Health Care (Fortune.com)
"Thus it may come as a surprise to learn that the managed-care industry is dying. Oops, did we spill the beans so soon? Well, so be it. Managed care is on the way out."

 

[PDF]Len Nichols Final Testimony.doc

 

 

 

 

 

 

 

 

 

 

Recession Forces 2.3 Million Households to Delay Retirement (Business Wire via International Foundation of Employee Benefit Plans)

 

 

Business Health Care Group at 43 members (Milwaukee Journal Sentinel via BCBSA)

 

 

UnumProvident Study Shows 10% of Employees Cause More Than Half of Medical Costs (PR Newswire via NewsAlert.com)

 

CFO.com

Bitter Medicine

"Small companies will be forced to make tough decisions if they are to survive another round of health-care cost increases."

 

Benefits Nearly 40% of Payroll, Study Finds

 

Health Costs #1 Benefit Worry, Survey Finds

 

Rising Medical Costs: Pass 'Em On (CFO.com)

Excerpt: "What do companies plan to do about the recent huge increases in health-care costs? No surprise here: 83 percent of the surveyed companies indicated they would increase employee premium contributions. Another 80 percent plan to increase employee co-pays/cost-sharing."

 

Businesses Slashing Medical Benefits
 
(CFO.com)

"In case you're still not convinced that health care is the next great corporate crisis, read on.

According to a nationwide survey of 600 large and small businesses, 92 percent say they are likely to increase the amount their employees pay for health-insurance premiums next year."

 

Union official urges health care reform-(Manitowoc Herald Times Reporter)

 

Health Savings Accounts for Multiemployer Funds (PDF) (The Segal Company)


 

 


 

 

Cutting Corners on Health Insurance (The [Fort Collins] Coloradoan)


 

 

California Governor, Doctors Concerned about Federal Malpractice Proposal (The Sacramento Bee via NewsAlert.com)

Excerpt: "As doctors nationwide press Congress to copy a California law that limits damages in malpractice lawsuits, many in California-- including the governor and the state medical society-- fear the federal legislation may undermine state HMO reform efforts.... Washington efforts to borrow a page from Sacramento, however, may stamp out a cornerstone of patients' rights here: the ability to sue HMOs for unlimited damages.....

The House bill won't do anything to reduce malpractice insurance premiums for doctors. All it will do is make it impossible for patients to sue HMOs."


 

 

 

 

 

Consumer Participation Seen as Key to Controlling Health Costs (Reuters Health via Medscape; one-time registration required)

"
Conference attendee Joe Baker, chief of the New York State Attorney General's office healthcare bureau, however, found the proposed solutions to the latest healthcare crisis to be tainted by a "blame the victim" mentality."
 

 

39 PERCENT OF DOCTORS SURVEYED REPORT MANIPULATING REIMBURSEMENT RULES TO HELP PATIENTS

One in Four Support Doctors Who Lie to Insurers

(Reuters Health)
"A quarter of the US public has no qualms about a doctor deceiving an insurance company in order to obtain health services for their patients, according to survey results reported on Tuesday.

.....

Alexander said the findings suggest physicians and insurance companies "need to work together to ensure that the appeals process is as streamlined as possible."

 

AARP Accused of Conflict of Interest Over Health Insurance Provisions In Medicare Bill (USA Today)

 

 

Thousands of Former Bethlehem Steel Employees Scramble for Health Coverage (The [Philadelphia] Inquirer)

 

Excerpt: "More than 200,000 retired steelworkers and their dependents-- including 95,000 from Bethlehem Steel and its Lukens division-- have lost health-insurance coverage in recent years, as 37 steelmakers have gone into Chapter 11. Union leaders say it is just a matter of time before retirees in other industries-- such as airlines-- are faced with the same experience."

 

Bethlehem Retirees to Fight Health Cuts
(Austin American Statesman)

 

Court OKs Beth Steel's benefits cut
(Baltimore Sun, MD)

 

Maryland General Assembly Votes to Allow Bethlehem Steel Retirees Into State-Backed Health Plan (The Baltimore Sun)

 

 

GAO Report: Improvements to Retirement Income Data Needed (U.S. General Accounting Office)

"What GAO Recommends:

The Congress should consider directing Labor to obtain from plan administrators electronic filings of SPDs and summaries of material

modifications and make them publicly available."

 
 

 

 

2003 State Legislators' Guide to Health Insurance Solutions (pdf)

Press Release

(Council for Affordable Health Insurance and the American Legislative Exchange Council)

 

Insurers Seek 1 Regulator Instead Of 50 - from TBO.com

"After more than 150 years of state-by-state regulation, many of the biggest insurance companies are leading a revolution to establish a federal regulator in Washington and shift state regulators to a secondary role."

 

New Momentum for Letting U.S. Help Regulate Nation’s Insurers (NYTimes.com)

 

Rep. Oxley Presents Plan for National Insurance Regulation - Kaisernetwork.org

 

 

Attitudes to Government Regulation Vary Greatly for Different Industries
The Harris Poll® #19, April 2, 2003
"
On the other hand, only very few people believe that tobacco companies (3%), managed care companies (4%), oil companies (4%), and health insurance companies (7%) are generally honest and trustworthy.

There is, clearly, a strong correlation between trust and the need for regulation. While there are some exceptions, the lower the level of trust, the greater the perceived need for regulation. Industries that want to avoid onerous regulation need to work hard at earning the public’s trust"

 

 

 

 

 

 

Mistrust Between Doctors, Insurance Companies Feeds Paperwork Logjam (The Boston Globe)

Excerpt: "The system is broken when it takes one administrative worker for every five doctors to get bills paid, executives who run the Massachusetts General Physicians Organization argue.... But the best software programmers in the world can't write enough code to solve the mistrust and stubborn thinking that's keeping health care years behind other industries in the use of technology to lower administrative costs."

''There is no innate trust in the transaction like there is in other industries,'' said James Heffernan, chief financial officer for the Mass. General physicians' group. As a result, he said, much of the money being poured into medical premiums ''isn't going into patient care.''

 

 

Sourcebook: Covering Health Issues 2004 (Alliance for Health Reform)

 

 

 

 

 

 

DOWNLOAD ENTIRE SOURCEBOOK (pdf, 5MB)

 

2005 State Legislators' Guide to Health Insurance Solutions and Glossary (PDF) (The American Legislative Exchange Council and The Council for Affordable Health Insurance)

 

 

A Bad Year for Benefits Costs (CFO.com)

 

Excerpt: "From the point of view of private-sector employers, it's been a disastrous year for benefit costs. For the year ended March 2003, benefit expenses leaped 6.1 percent, greater than the 4.8 percent jump for the year ending March 2002, according to figures just released by the U.S. Bureau of Labor Statistics. State and local government employers had similar boosts: 6.6 percent in benefits and 3.1 percent in wages and salaries."

 

 

 

 

 

An Employer's Guide to Patient-Directed Healthcare

(65-page PDF book)

(Wye River Group on Healthcare)

 

An Employer's Guide to Pharmaceutical Benefits

(75-page PDF book)

(Wye River Group on Healthcare)

 

Consumers Take Charge: Defined-Contribution Health Plans (PDF) (The Wharton School of the University of Pennsylvania)

 

Defined Contribution Health Plans-- a Green Light for Health Reimbursement Arrangements (PDF) (Mark L. Stember, Esq. of Kilpatrick Stockton LLP)

 

Where Is the Consumer-Directed Healthcare Movement Headed in 2004? (Inside Consumer-Directed Care via AISHealth.com)

 

Technology Reshaping HR Function (CFO.com)

 

Health Care Benefits 2003:
A Towers Perrin Point of View...

 

The Changing Face of Health Care: Balancing Employer and Employee Needs
TP Track Survey
(
Towers Perrin)

 

Self-Insured Healthcare Risk-- Take It or Leave It? (PDF) (Milliman USA) (At pages 8 through 11 of 12-page document)

 

Will Employers Transform Healthcare? (PDF) (Milliman USA) (At pages 4 through 7 of 12-page document)

 

Health Care Costs Force Benefit Changes (USA TODAY)

 

Health Insurers Unveil New Products for 2004 (Managed Care Week via AISHealth.com)

 

Savings from consumer-directed health care under debate
(Centre Daily Times, PA)

 

Managing Health Care Costs: Back to Basics (PDF) (Strategic Benefit Advisors, Inc.)

 

Making Wellness the Focus: One Employer's Story (Aon Consulting)

 

Opinion: When Are Health Costs Excessive If $15,000 Is Average? (C. Eugene Steuerle published by the Urban Institute, courtesy of Tax Analysts)

 

Cost Shifting: New Myths, Old Confusion, and Enduring Reality (Health Affairs)

 

Medicare Payment Policy: Does Cost Shifting Matter? (Health Affairs)

 

Can Hospitals and Physicians Shift the Effects of Cuts in Medicare Reimbursement to Private Payers? (Health Affairs)

 

Aon's Fall 2003 Health Care Trend Survey (Aon Consulting)

The Relationship Between Technology Availability and Health Care Spending (Health Affairs)

Overview: Pay or Play in California? (PDF) (Seyfarth Shaw LLP)

Employers Looking At Cost of Family Health Coverage (USA Today)

Contain Rising Health Care Costs With Strategy and Education (Aon Consulting)

Health Savings Account Can Be Tax Shelter (USA Today)

 

 

 

 

Health Care Costs Stabilize But Remain High In 2002 (Health Affairs)

Also Available in PDF

Excerpt: "Nonetheless, health care spending grew nearly four times faster than the U.S. economy grew in 2002."

 

 

 

Hello, Rising Health Care Costs; Goodbye, Non-Essential Benefits

(BenefitsNext)

 

Wal-Mart's Benefits Come under Fire
(
By Janet Adamy
CONTRA COSTA TIMES)

 

HMO or PPO: Picking a Managed Care Plan (Consumer Reports)

 

Changing Insurance Plans Could Be Hazardous to Your Health (HealthDay via Yahoo! News)

 

Poll: Public Supports Health Care for All (AP)

 

Opinion: a Watershed Strike (Kelly Candaele & Peter Dreier in The Nation)

 

Insured Americans Drive Surge in Emergency Department Visits

News Releases

(hschange.org)

 

Health Insurance Payers Refine Cost-Sharing Techniques to Target Patient Behavior, Treatment Choices (Managed Care Week via AISHealth.com)

 

Employers Stay Committed As Healthcare Costs Soar (BenefitNews.com)

 

Health Plan-Provider Contract Showdowns Subside (Center for Studying Health System Change)

 

Message From Employees to Management: Tell It to Us Straight (Towers Perrin)

 

Insurance CEOs are in the money ... AMNews: May 3, 2004.

 

Hospital CEO salaries show modest increase ... AMNews: Nov. 3, 2003.

 

 

Mayo Clinic Asked to Open Books
(Brainerd Daily Dispatch)
 

"The letter says medical providers set "uniform charge master lists" that classify rates for each service offered. It says a preliminary investigation, though, shows rates are often inflated beyond actual costs because providers "need to make up for the steep discounts from prices demanded by the third-party health plans" such as health maintenance organizations and other insurers."

 

 

HMOs Almost Always Reverse Denials for Emergency Room Care (The Commercial Appeal)

Excerpt: "Denials of emergency room coverage are almost always reversed and claims are paid if the decisions are appealed, according to a new study of claims at two large California HMOs."

 

Annals of Emergency Medicine February 2004

Disputes over coverage of emergency department services: A study of two health maintenance organizations (Original Research)

ABSTRACT
FULL TEXT
PDF

Results: "Enrollees won more than 90% of appeals."

Conclusion: "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."

 

 

   
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