|
What is ERISA Brainstorming
for
Healthcare
Executives?
"UCR": $5,000/day/Individual;
$10,000/day/Group
CALL: 1-630-736-2974
Please e-mail for more details
Maximal Healthcare Claim Reimbursement
through ERISA Compliance
CMS New Appeal Rules:
"Overhaul of the Medicare Claims Appeals System"
Breaking News
950,000 MD's Settled With Aetna & Cigna on ERISA
"Aetna
and CIGNA Settlement Secrets"
"Talking
Points"
What You
Should Know about Filing
Your Health Benefits Claim
(DOL Claims Card)
U.S. Health-care Crisis & ERISA Criminal Enforcement
Are All
Consultants Corrupt? (Fast Company)
|
For
CFO's,
COOs,
Denial Management
Dept.,
Managed Care Directors,
Contract Managers,
A/R Specialist,
Reimbursement
Manager,
Office Manager, Coder's/Biller's,
Patient Accounting Directors And
Managers,
Risk Managers, Revenue Cycle Directors,
Claims/ Benefit Managers,
"Provider
Sponsored Organization" of HMO's, IPA's &
"Integrated
Health Systems/Networks"
Providers, Payers And Suppliers,
Employer, Insurer,
TPA's,
Appeals Dept., HR,
and More.....
|
|
Conclusion
or Confusion?
© 2005,
Jin Zhou,
ERISAclaim.com
ERISAclaim.com - CMS New
Appeal Rules: "Overhaul of the Medicare Claims Appeals System"
Based on our
comprehensive and diligent study of this new Medicare appeal process,
and our extensive experience in ERISA
claim procedure practice, and
"in view of the wide span of
applicability of these rules and the complex, intertwined nature of
the affected appeal procedures,"
[page 2 of 511] it is our conclusion that our nation
must recognize and create a new profession, separated from and/or in
addition to traditional Coding and Billing personal:
"Medicare Appeals Specialist"
Guerrilla and
weekend training without systematic and quality education will
definitely fail in Medicare reimbursement because of its broad
requirement and "Authorized Representative" practice with "a waiver of
the assignee's right to collect payment...."
"Medicare
Appeals Specialist" and "ERISA
Claims Specialist" will be the crown of US healthcare
reimbursement.
This is why
Congress and CMS created QIC
(="Appeal Specialists" with dual and "sufficient
medical, legal, and other expertise", § 405.968 (c) (1) [page 394 of
511]) separated FROM and in addition to Medicare Claim Processors
(Medicare FI's & Carriers),
(Among the major
changes required by the BIPA amendments are--......Requiring the
establishment of a new appeals entity, the qualified independent
contractor (QIC), to conduct
“reconsiderations” of contractors’ initial determinations (including
redeterminations, [page 15-16 0f 511]).
And this is
also why Congress enacted ERISA 30 years ago to require "an
appropriate named fiduciary of the plan",
§ 2560.503-1(h) (1), rather than a claim processor or ASO
(Administrative Services Only) TPA (Third-Party Administrator) to
handle ERISA health claim appeals.
Conclusion or
Confusion? Your choice and decision.
Jin Zhou,
ERISAclaim.com, 03/08/2005 |
|
Medicare New Appeal &
Reimbursement Seminars
New Compliance &
Challenges
Toll-Free Numbers and Websites
for
Your
Carrier/Fiscal Intermediary |
|
Seminar I 2
days |
Seminar II
2 days |
Seminar III
2 days |
|
New Medicare Appeal
Process & Mandates v.
Former Process
|
New Medicare Appeal
Strategies for
Reimbursement
Success
&
-
Documentation
-
Fraud And Abuse
-
Medical Review
-
National Correct Coding Initiative
(NCCI)
-
more
|
New
Medicare Appeal Laws
Intertwined
with($183
million/y)
ERISA Claims Laws |
|
Unanimous US Supreme Court Ruling
In US Health Care Crisis
& Maximal Healthcare Claim Reimbursement
by Jin Zhou,
02/11/2005
© 2005,
Jin Zhou,
ERISAclaim.com
Managed-Care Nightmares?
Maximal Healthcare Claim Reimbursement
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.
ERISAclaim.com: "employer-sponsored group health plans"
=
"ERISA-regulated benefit
plans",
both self-insured and
fully-insured (through purchase of insurance) health plans,
(ERISA - Title 29, Chapter 18.
Sec.
1002.)
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."
|
|
Hospital CEO's Confessed Their Biggest Headaches:
Financial Challenges from Unpaid/Denied Medical Bills in 2004 |
|
71% of CEO's, out of 460
surveyed by American College of
Healthcare Executives ( ACHE)
in 2004, identified No.
1 headache, among other things, as financial challenges. Top 5
problems of financial troubles: Medicaid 78%, Bad Debt 72%,
Medicare 70%, Revenue Cycle Management 53% and Managed-care
Payments 52%. Care for the uninsured and personnel shortage were
ranked as No. 2 and No. 3 pressing issues. For more details, go to
ACHE's
Top Issues Confronting Hospitals: 2004
Dr. Jin Zhou, President of ERISAclaim.Com, has
strongly
advocated for the Hospital CEO's and the
entire health care industry to utilize and comply with the
superpower of ERISA, federal law, governing health care denials
and
to create a new line of occupation, claim
appeals specialist, to cope with industry claim denial crisis,
soon
to be tripled in 2005.
Getting paid through ERISA compliance instead of abuse and fraud.
OIG: Special Advisory Bulletin: Practices
of Business Consultants
[PDF]
Testimony of Lewis Morris
[PDF]
[http://oig.hhs.gov/fraud/docs/alertsandbulletins/consultants.pdf]
The Office of Inspector General (OIG), Department of Health
and Human Services, June, 2001
|
|
Tort Reform, Fraud & Healthcare Crisis? |
|
New From Center for Justice & Democracy:
***New Study*** Falling Claims and
Rising Premiums in the Medical Malpractice Insurance Industry
(July 7, 2005)
Appendix
News Release: New Study Leads
Attorneys General to Proclaim “No Excuse” and “A Matter of
Life and Death” (July 7, 2005)
PDF
"Joanne
Doroshow, Executive Director of the Center for Justice &
Democracy, which commissioned the report, stated, “To put it
bluntly, if you look at what the insurance companies say about
why they raise premiums, and then look at the data in this
report, thenumbers just don’t add up. The facts are very
simple: medical malpractice payouts are down yet insurance
companies have significantly increased premiums.
This shows that the
entire campaign to limit liability for doctors over the last
several years by capping compensation to injured patients has
been a fraud, and that based on these data, insurers must know
that it has been a fraud.”
Study Backgrounder (July 7, 2005)
PDF
|
|
ERISAclaim.com - A $1.0 Trillion Nuclear
Solution to U.S. Health-care Crisis & $44 Trillion Budget Deficits |
Title 29 U.S.C. § 1141 states:
"It shall be unlawful for any
person through the use of fraud, force, violence, or threat of
the use of force or violence, to restrain, coerce, intimidate,
or attempt to restrain, coerce, or intimidate any participant or
beneficiary for the purpose of interfering with or preventing
the exercise of any right to which he is or may become entitled
under the plan, this title, section 3001, or the Welfare and
Pension Plans Disclosure Act. Any person who willfully violates
this section shall be fined $10,000 or imprisoned for not more
than one year, or both. The amount of fine is governed by 18
U.S.C. § 3571. The U.S. Sentencing Guidelines address 29 U.S.C.
§ 1141 under the guidelines for "Fraud and Deceit" (U.S.S.G. §
2F1.1) or for "Extortion by Force or Threat of Injury or Serious
Damage (U.S.S.G. § 2B3.2)......"
"For example, Section 1141
would reach the use of deception directed
at misleading a welfare plan beneficiary as to the amount of
health benefits owed to the beneficiary under the terms of the
plan or at misleading a pension plan participant as to
the amount of retirement benefits to which he would become
entitled under the plan upon his retirement."
ERISA in the United States Code
|
ERISAclaim.com - CMS New Appeal
Rules: "Overhaul of the Medicare Claims Appeals System"
|
Meyer Medical Physic v. Health Care
Service
7th Cir. 09/23/2004
"ROVNER, Circuit Judge. After Meyer Medical Physicians Group, Ltd.
(“Meyer”) filed a voluntary petition for relief under Chapter 11, the
bankruptcy court granted a motion by a creditor, Health Care Service
Corporation d/b/a HMO Illinois (“HCSC”), to effectuate a setoff of
approximately $1.3 million against amounts owed by Meyer. The district
court affirmed the bankruptcy court’s discretionary decision, and Meyer
appeals. We affirm."
N.J. Medical Society Goes to Court To
Block Recoupment of $15M in Alleged
Overpayments (11/30/2004, AP via
Insuarnce Journal)
"The Medical Society of New Jersey is seeking
court action to prevent an insurance company from
recouping $15 million in alleged
overpayments to doct | |
