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at 11:57:03 AM on Friday, November 21, 2003

We Are Seeking New Strategic Partners

 

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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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)

 

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"UCR":  $5,000/day/Individual; $10,000/day/Group

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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)

 

 

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

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2 days

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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."

 

A Consumer Guide to Handling Disputes with Your Employer or Private Health Plan -- 2005 Update (Kaiser Family Foundation)

 

What You Need to Know About Your Employer-Sponsored Coverage

"If you are enrolled in an employer-sponsored health plan, your right to appeal disagreements about benefits through your plan’s internal appeals process is determined by federal law (the Employee Retirement Income Security Act, or ERISA) and a federal ERISA regulation that became effective January 1, 2003." 

Full Report (pdf)

 

USNews.com: Health: In Brief: Public Health: Winning fights with your HMO (8/12/05)

 

 

 

 

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

 

 

Aetna, CIGNA CEOs Got 8-Figure Pay Packages (Connecticut Business, March 22, 2005)

"Dr. John W. Rowe, Aetna's chairman and CEO, took in $22.2 million in 2004, including $18.2 million of value from exercising stock options. He also got 250,000 new stock options with a potential value of $6.1 million."

 

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

 

DOJ: Criminal Resource Manual 2432 Coercive or Fraudulent Interference with ERISA Rights -- 29 U.S.C. 1141

2432 Coercive or Fraudulent Interference with ERISA Rights -- 29 U.S.C. 1141

Title 29 U.S.C. § 1141 states:

 

"It shall be unlawful for any person through the use of fraud, force, violence, or threat of the use of force or violence, to restrain, coerce, intimidate, or attempt to restrain, coerce, or intimidate any participant or beneficiary for the purpose of interfering with or preventing the exercise of any right to which he is or may become entitled under the plan, this title, section 3001, or the Welfare and Pension Plans Disclosure Act. Any person who willfully violates this section shall be fined $10,000 or imprisoned for not more than one year, or both. The amount of fine is governed by 18 U.S.C. § 3571. The U.S. Sentencing Guidelines address 29 U.S.C. § 1141 under the guidelines for "Fraud and Deceit" (U.S.S.G. § 2F1.1) or for "Extortion by Force or Threat of Injury or Serious Damage (U.S.S.G. § 2B3.2)......"

 

"For example, Section 1141 would reach the use of deception directed at misleading a welfare plan beneficiary as to the amount of health benefits owed to the beneficiary under the terms of the plan or at misleading a pension plan participant as to the amount of retirement benefits to which he would become entitled under the plan upon his retirement."

 

ERISA in the United States Code

ERISA 510 29 USC 1140 Interference with protected rights.
ERISA 511 29 USC 1141 Coercive interference.

 

Department of Justice Seal Department of Justice

FOR IMMEDIATE RELEASE
THURSDAY, DECEMBER 30, 2004
WWW.USDOJ.GOV

 

#807: 12-30-04 HEALTHSOUTH TO PAY UNITED STATES $325 MILLION TO RESOLVE MEDICARE FRAUD ALLEGATIONS

"WASHINGTON, D.C. - HealthSouth Corporation, the nation's largest provider of rehabilitative medicine services, has agreed to pay the United States $325 million to settle allegations that the company defrauded Medicare and other federal healthcare programs, the Department of Justice announced today."

 

HHS-OIG-Corporate Integrity Agreements

 

OIG: Special Advisory Bulletin: Practices of Business Consultants [PDF] [http://oig.hhs.gov/fraud/docs/alertsandbulletins/consultants.pdf]
The Office of Inspector General (OIG), Department of Health and Human Services
, June, 2001

 

 

ERISAclaim.com - CMS New Appeal Rules: "Overhaul of the Medicare Claims Appeals System"

 

CMS News on Wheelchair and Medical Necessity

December 15, 2004: MEDICARE OPENS NATIONAL COVERAGE DETERMINATION TO MAKE SURE BENEFICIARES WHO NEED WHEELCHAIRS GET THEM

 

October 18, 2004: MEDICARE BENEFICIARIES WILL SOON BE ABLE TO RESOLVE MEDICARE APPEALS FASTER

 

"Other steps that CMS is taking as part of its comprehensive overhaul of Medicare claims appeals include:
  • Finalizing the transfer of responsibility for the third level appeals conducted by Administrative Law Judges from the Social Security Administration to the Department of Health and Human Services by October 1, 2005.
  • Developing a new appeal-specific data system that will allow authorized users to track  individual appeals in real time.
  • Establishing an Administrative QIC that will oversee the distribution of case-files, develop appeals processing protocols, conduct training of the QICs, and the dissemination of information on QIC appeals decisions to the public
  • Implementing a 60-day decision deadline and improved notices for claims redeterminations, or first-level appeals performed by fiscal intermediaries and carriers.   The improved notices will include the specific reasons for the decision and a summary of relevant clinical or scientific evidence used in making the decision.

Issuing the final regulations needed to implement the new uniform appeals procedures, including the rules QICs and other appeals entities by the end of the year."

 

Maximum Comfort, Inc v. Tommy G. Thompson

(06/30/2004, United States District Court for the Eastern District of California)

 

RenCare Ltd vs. Humana Health Pln TX (5th Cir. 12/30/2004)

 

 

 

 

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 doctors.

 

The society is seeking an injunction against Horizon Blue Cross/Blue Shield, which claims that over two years it overpaid more than 600 doctors who performed heart procedures. The insurer has asked the physicians to give back the money by Nov. 30."

Doctors sue to block $15 million repayment (Newark Star Ledger, NJ - Nov 29, 2004)

 

Some health care costs unnecessary (APP.COM)

 

"In recent months, Horizon has seen a dramatic increase in the number of claims it is receiving, Marino said. New Jerseyans, he said, are receiving more health care yet, "the higher volume of services does not translate into improved quality."

Health Care Analysts See Bleak Outlook for Hospitals with Reimbursement Changes (The New York Times; one-time registration required)

Excerpt: "Chill is in the air for hospitals accustomed to having insurers - both public programs like Medicare and private health plans - pay ever higher prices for hospital services. That era appears to be ending, some analysts say."

 

 

 

ERISAclaim.com provides today's health-care executives with a completely unique and unprecedented solution, through brainstorming on today's health-care crisis assessment, vital strategies to practical implementations for business bottom-line:

 

Fraud Health Care Cards
"New Strike Force"

Medical Fraud Every Day?

Appeal or Re-Bill After Denial?

You Must APPEAL

No Re-Billing!!!

Claim Appeal or Sentencing Appeal?

Your Choice
Maximal Reimbursement
through ERISA Appeal &

Fraud Prevention and Compliance

 

MEDICARE OVERPAYMENTS REACHED NEARLY $20 BILLION IN 2003, NEW SURVEY FINDS (PharmExec)

 

CMS ANNOUNCES IMPROVED EFFORTS TO REDUCE MEDICARE PAYMENT ERROR RATES (12/13/2004, CMS Press Release)

 

CMA Rebuts Health Plan Allegations of Unfair Physician Billing Practices [Posted 11/11/04] 

Click here to download CMA's letter to DMHC.

 

Blue Cross And Blue Shield Plans File $30 Million Lawsuit Alleging Rent-A-Patient Fraud In Southern California (BCBSA.com, 03/11/2005)

 

MAINE UROLOGIST SENTENCED FOR HEALTHCARE FRAUD (United States Department of Justice) October 6, 2004

 

Aetna:  Leading the Fight Against Health Care Fraud [PDF] View as HTML

"Thanks to this highly collaborative relationship, we know how to identify fraud because we know what to look for.

 

Medical Fraud

  1. Unusual provider billing practices.

  2. Discrepancy between the submitted diagnosis and the treatment.

  3. Diagnoses or treatments that are outside the practitioner’s scope of practice.

  4. Claims that are resubmitted with coding changes to gain benefits.

  5. Alterations on claim submissions.

  6. Pressure for quick claim payment."

Payments Go Under a Microscope (washingtonpost.com) January 12, 2004

"MAMSI and CareFirst recoup overpayments to doctors by making deductions from future reimbursements. Doctors can appeal insurers' decisions. But, in the end, they usually pay up, doctors and insurers agree."

Employers Audit Workers' Health Claims (Wall Street Journal via SFGate.com)  baltimoresun.com - Health plan 'stings' on rise

Excerpt: "Looking to bring down soaring health-care costs anywhere they can, more employers are scouring their health plans for fraud, abuse and simple mistakes by employees or administrators.

.......The number of requests for such audits jumped 50 percent last year, Mr. Farley estimates."

Blue Cross and Blue Shield Association Announces New Strike Force to Protect American Consumers from Fraud and Fight Rising Costs (U.S. Newswire, 4/19/2004)

"DETROIT, April 19 /U.S. Newswire/ -- The Blue Cross and Blue Shield Association (BCBSA) today announced a new Anti-Fraud Strike Force comprised of top Blue Plan investigators that will work with the Federal Bureau of Investigation (FBI) and other national, state and local law enforcement agencies to fight major insurance fraud schemes that rob consumers of millions of dollars annually. BCBSA President and CEO Scott P. Serota announced the new initiative in a speech to the Detroit Economic Club."

 

"The National Health Care Anti-Fraud Association (NHCAA) estimates that healthcare fraud costs American consumers more than $50 billion annually. Billing for services not rendered and misrepresentation of provided services are the most common types of healthcare fraud."

Task force targets health care cheats - (04/20/04, The Detroit News) 

BlueCross Seeks Consumer Help in Fighting Insurance Fraud

 

 

Clinton Township Firm Convicted of Overbilling (Macomb Daily)

"The case is somewhat unusual in that a corporation was named as a criminal defendant in the case, but Kaiser said that is not unheard of since corporate law can make a firm liable for criminal wrongdoing, and its principal office holders in return are responsible for any judgments or punishments the courts impose.

David Griem, the defense attorney for Emergency Management who was also named the principal to enter a guilty plea on its behalf, also could not be reached for comment after the sentencing hearing. In court, however, he turned over a check to the Blue Cross insurance company officials in attendance and said the company would pay the $5,000 court costs on time as well."

A prosecutor accuses hospital of bribing doctors (The Wall Street Journal)

"Prosecutors have filed charges against ......, accusing them of bribing doctors with "relocation agreements" in exchange for the doctors' referral of patients to the hospital. Such agreements are a well-established practice in the U.S. But now, they're under threat amid the debate over skyrocketing health-care costs.

 

Leading the government charge in the Alvarado case is Carol C. Lam, the U.S. attorney in San Diego. .... She filed criminal charges against Mr. Weinbaum personally, putting executives on notice that they could go to prison if their hospitals make illegal contracts."

Medicare | Fraud, Abuse in Medicare and Medicaid Could Exceed Government Tracking Figures - Kaisernetwork.org

 

"In a statement, Sen. Larry Craig (R-Idaho), Chair of the Senate Special Committee on Aging, said, "In these tight budgetary times, it is important that every dollar that the federal government spends be well spent for its intended purpose ... But as we go after waste, fraud and abuse within Medicare, we need to make sure that we do not overreact."

Health Care Now Prime Target of Federal False Claims Act (AM News)

 

"The reason government investigations and prosecutions are so efficient is that whistle-blowers act like bird-dogs that point out the fraud and flush it to the government attorneys," said James Moorman, president of Taxpayers Against Fraud. "Without the whistle-blowers, the federal government just can't find the fraud."

"70% of False Claims Act recoveries in 2003 came from suits initiated by whistle-blowers."

"Without a doubt there is still a lot of fraud to be found, but the False Claims Act is clearly changing corporate culture in the health care arena," said health economist Jack Meyer, who authored the report.

 

"A few years ago, health care consulting firms were advising companies about how to beat the system by cooking the books, Meyers said. Now those same consulting firms -- some of which were prosecuted under the False Claims Act for encouraging fraud -- are advising the industry on how to comply with the letter of the law and stay out of trouble, he said."

"No place for fraud"

"There is no place for fraud in the practice of medicine," said AMA President-elect John C. Nelson, MD. "However, it is important that as the government investigates health care fraud, there is recognition, and separation, of inadvertent errors by health care professionals from real fraud."

Insurers make only small dent in medical-claims fraud (cbs.marketwatch.com)

"Byron Hollis, national antifraud director for the association, said the association plans to escalate its fight against fraud and noted that the group increased its investigative staff to 500 in 2003, up 30 percent from fewer than 400 the year before."

 

"He noted that the association's insurers still might recover more of last year's fraudulent claim payments because some of the cases have yet to go to court."

Maximum Comfort, Inc v. Tommy G. Thompson (06/30/2004, United States District Court for the Eastern District of California)

 

U.S. Department of Justice Seal

Health Care Fraud Report

Fiscal Year 1998

Link to Site Map

USDOJ: Deputy Attorney General: Publications and Documents - - Health Care Fraud Report Fiscal Year 1998

 

"On June 4, 1998, in the District of Maryland, Levindale Geriatric Hospital paid $800,000 to resolve allegations it violated the FCA by recoding and resubmitting denied charges for room and board. After the claims for room and board were denied by the Medicare Part A program, Levindale recoded the claims as supplies, laboratory work and other services, and submitted the claims for payment. In addition to paying a substantial penalty under the FCA, Levindale entered into a compliance agreement with HHS-OIG"

 

Docs Urged to Collect Fees -- Co-Payments and Deductible Payments -- Up Front (MSNBC News)

 

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]

 

"Class Actions" v. "New Strike Force"

 

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

Medicare | Fraud, Abuse in Medicare and Medicaid Could Exceed Government Tracking Figures - Kaisernetwork.org

 

"In a statement, Sen. Larry Craig (R-Idaho), Chair of the Senate Special Committee on Aging, said, "In these tight budgetary times, it is important that every dollar that the federal government spends be well spent for its intended purpose ... But as we go after waste, fraud and abuse within Medicare, we need to make sure that we do not overreact."

GAO: HEALTH CARE Consultants’ Billing Advice May Lead to Improperly Paid Insurance Claims, June 2001

"In summary, the two workshops about which we raise issues in this report offered in-depth discussions of regulations that pertain to billing for evaluation and management health care services2 and compliance with health care laws and regulations. During the course of discussions at those workshops, certain advice was provided that is inconsistent with guidance provided by the Department of Health and Human Services’ Office of Inspector General (OIG). Such advice could result in violations of both civil and criminal statutes. Specifically, certain consultants advocated not reporting or refunding overpayments received from insurance carriers after they were discovered. The consultants also encouraged the performance of tests and procedures that are not medically necessary to generate documentation in support of bills for evaluation and management services at a higher level of complexity than actually confronted during patients’ office visits. ...."

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

 

Health Care Now Prime Target of Federal False Claims Act (AM News)

"No place for fraud"

"There is no place for fraud in the practice of medicine," said AMA President-elect John C. Nelson, MD. "However, it is important that as the government investigates health care fraud, there is recognition, and separation, of inadvertent errors by health care professionals from real fraud."

 

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)

 

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

 

 
 

 

 

New Study: ER Denials?
Medical or ERISA Appeals? Appeals!

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

"There are two take-home messages for health professionals," Hall said. "One, insurers much less often question the appropriateness of emergency services"  = not about Medical necessity; 

 

"and two, if insurers initially deny coverage for emergency care, providers or patients should appeal."  = ERISA Appeals

 

"However, some compliance problems did emerge. Some insurers, Hall told Reuters Health, initially deny ED claims and then "quickly reverse" their decision if challenged."  = always denials.

"Prudent Layperson" Laws Do Not Increase Inappropriate ED Visits (Reuters via Medscape; one-time registration required)

"However, some compliance problems did emerge. Some insurers, Hall told Reuters Health, initially deny ED claims and then "quickly reverse" their decision if challenged.

 

"There are two take-home messages for health professionals," Hall said. "One, insurers much less often question the appropriateness of emergency services and two, if insurers initially deny coverage for emergency care, providers or patients should appeal."

 

The impact and enforcement of prudent layperson laws (Mark A. Hall, JD, Annals of Emergency Medicine Online, May 2004 • Volume 43 • Number 5)

[ABSTRACT]  [FULL TEXT] [ 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."

 

HCA Previews First Quarter Results

"As a result, the Company's provision for doubtful accounts in the first quarter is expected to be $694 million (11.7 percent of net revenues) compared to $428 million (8.1 percent of net revenues) in the first quarter of 2003."

 

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."

 

Employers Audit Workers' Health Claims (Wall Street Journal via SFGate.com) & (MLive.com, MI)

Excerpt: "Looking to bring down soaring health-care costs anywhere they can, more employers are scouring their health plans for fraud, abuse and simple mistakes by employees or administrators.

.......The number of requests for such audits jumped 50 percent last year, Mr. Farley estimates."

USATODAY.com - Hospitals Sock Uninsured with Much Bigger Bills

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

 

 

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%

 

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


Maximal Healthcare Claim Reimbursement
through ERISA Compliance

 

What is ERISA Brainstorming

for Healthcare Executives?

 

Federal Law, ERISA, regulates and governs approximately 80% of U.S. health-care claims and 60% of national health-care expenditures while in past two decades health-care executives are historically and practically clueless about this ERISA statutory and regulatory superpower for their business survival and development.

 

We also provide unique ERISA compliance brainstorming to health executives of integrated health systems, when more and more health-care provider sponsored health networks are integrating their providers and hospitals into integrated health networks as provider sponsored health plans.  No matter who administers health benefit plans, insurers or health-care providers, ERISA compliance shall be the number one priority for any integrated health system in dealing with ERISA plans, or employer-sponsored health plans in private sectors including both self-funded and fully-insured health plans.

 

The latest and updated RAND/Harvard Study, funded by the U.S. Department of Labor (DOL) and requested by Congress, examines the outcomes of nearly a half-million coverage requests in two large medical groups and revealed the following:

 

 

More than 70% of healthcare claims denied or delayed each year were Not because of coding or billing errors or disputes, but due to non-coding and non-billing related reasons, such as policy exclusion, medical necessity/utilization reviews, pre-existing exclusions, pre-certification, prior-authorization, PPO bundling and downcoding and "unknown" or unexplained reasons. Yet all denials and delays were handled by coding and billing staffs, while up to 80% of healthcare claims are ERISA claims and these coding and billing staffs have no training and knowledge in ERISA, coverage dispute, appeal procedures. No one seems to know what to do, but do whatever they felt need to be done - going circles and frustrations every day.

 

 

State of Connecticut v. Health Net, Inc.,

11th Cir. 09/10/2004

State Can NOT Enforce ERISA, Publicly or Privately
(
ERISAclaim.com - Managed Care Court Watch)

 

Hawaiian Court Reverses Lower Court Ruling on ERISA Preemption of State Law on External Review

(The Supreme Court of the State of Hawaii)

Excerpt: "The Hawaiian Supreme Court ruled November 18, 2004, that a state law that gives Hawaii's insurance commissioner authority to conduct external reviews of health insurance plan decisions is 'impliedly' preempted by the Employee Retirement Income Security Act (ERISA)."

 

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)

 

 

ERISA Executive Power Guides

(Purified Verion)

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

ERISAclaim.com - ERISA, Who?

 

ERISAclaim.com - ERISA 1-2-3

 

ERISAclaim.com - New! On-site Programs for ERISA & New CMS/Medicare Compliance

 

ERISAclaim.com: An Unique Magic for Integrated Health Systems

 

ERISAclaim.com - HSA &/Or  ERISA? 95% of HSA Are Still ERISA's!

 

ERISAclaim.com - CMS New Appeal Rules: "Overhaul of the Medicare Claims Appeals System"

 

ERISAclaim.com: ERISA Demystified for
Providers, Insurers, TPAs, Patients,
Regulators and Legislators

 

ERISAclaim.com: What's New? You Must Comply with
New Federal Claim Regulations!

 

ERISAclaim.com - Managed Care Court Watch -
Superpower & Protections for Physicians

 

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

 

ERISAclaim.com: Prompt Pay Crisis & ERISA Solutions

 

ERISAclaim.com: How to Appeal
Downcoding & Bundling Claim Denials

 

ERISAclaim.com: Appeals  for Commonly Seen
Medical Claim Denials

with Superpower from Federal & State Laws

 

ERISAclaim.com - "Overpayment" Refund Request
& Recoupment Response & Appeals

 

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

 

 

ERISAclaim.com: 50% Savings - Healthcare Crisis Turnaround
for Employers, Insurers & TPA's

 

The Latest AMA (PSA) Managed Care Hassles Survey through nationwide state medical associations and national medical specialty societies identified the most popular and important managed-care claim denials and delays.

 

Top Seven Issues through National Medical Specialty Societies

Rank

Problems Reported By Popularity Rank

  %

1

Bundling

67%

2

Medical Necessity Decision Denials

43%

3

Prompt Payment

43%

4

Administrative Hassles

33%

5

Coding Issues

24%

6

Downcoding

19%

7

Bargaining Lack of Negotiation Power

14%

 

Top Eight Most Importantly & Frequently Listed Issues through
State Medical Associations

Rank

Problems Reported By Importance Rank

1

Downcoding & Bundling

2

Prompt Payment

3

Lack of Budgeting Power

4

Medical Necessity Denials

5

Prior Authorization of Med. Services

6

Health Plan Credentialing

7

Drug Formularies

8

Other

 

Despite the worst health-care crisis since World War II, health-care executives nationwide are clueless about ERISA in governing reimbursement and denial management, or are still in denial of reimbursement crisis resulted from lack of understanding of the ERISA, even ERISA regulates and governs 80 percent of health-care claims and 60 percent of health-care expenditure for 28 years, 60-80 percent of health-care or hospital business. Knowing nothing about ERISA is the reason for executive decision not to get involved with ERISA protections, or knowing little about ERISA being good for health-care providers justified refusing to know more about ERISA.
 

 

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."

Cash-poor UCLA hospitals hire turnaround firm  (Los Angeles Times)

"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."

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." 

Paperwork pileup  (The Boston Globe)

''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.''

 

"We, for better or worse, are buying more administration,'' Pauly said. ''We end up spending a lot, and in the end nobody's better off.'' He suggested, ''The best thing would be if they can somehow agree to a disarmament. But so far, nobody's found a way to do that.'' (The Boston Globe)

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."

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."

"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."

Subcommittee on Health Hearing on the Uninsured, Tuesday, March 09, 2004

 

Hospital Pricing and the Uninsured, Glenn Melnick, Ph.D., Director, Center for Health Financing, Policy and Management, University of Southern California, School of Policy, Planning and Development, Los Angeles, California

 

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 Cost of Care for the Uninsured: What Do We Spend, Who Pays, and What Would Full Coverage Add to Medical Spending? (Kaiser Commission on Medicaid and the Uninsured)

Issue Brief (.pdf)

News Release (.pdf)

"This issue update finds that uninsured Americans could incur nearly $41 billion in uncompensated health care treatment in 2004, with federal, state and local governments paying as much as 85 percent of the care. It also finds that if the country provided coverage to all the uninsured, the cost of additional medical care provided to the newly insured would be $48 billion."

82M U.S. Residents Uninsured at Some Point Over Last Two Years, Study Says - Kaisernetwork.org

 

One in Three: Non-Elderly Americans Without Health Insurance, 2002-2003 (Families USA)

 

Doctored Books (motherjones.com)

"Richard Scruggs sued Big Tobacco and won. Now, he's taking on some of the nation's biggest non-profit hospital chains on behalf of the uninsured."

Nonprofit Hospitals Said to Overcharge Uninsured (The New York Times)

"A group of plaintiffs' lawyers filed civil lawsuits against more than a dozen nonprofit hospitals across the country yesterday, contending that the hospitals violated their obligation as charities by overcharging people without insurance and then hounding them for the money."

 

A common sense question without executive intelligence: if ERISA regulates 60-80 percent of your health-care business revenue, why don't we want to know more about ERISA?

 

Any traditional and conventional appeals without ERISA COMPLIANCE are "squeaky wheel appeals" for any ERISA claim denials and delays, 80 percent of U.S. Healthcare claims and 60% of U.S. Healthcare expenditure.
 

 

 

 

ERISAclaim.com: What's New? You Must Comply with
New Federal Claim Regulations!

 

New York State Seal

New York State, Insurance Department

ISSUED 4/13/2004

FOR IMMEDIATE RELEASE

Health Net To Refund $4.99 Million To Policyholders And Re-Evaluate Some Healthcare Claims  (The full report, pdf)
Also Paid $500,000 Fine And Instituted Remedial Actions Under Separate Department Action

 

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 
March 30, 2004
New Report Shows HMOs Do Not Adequately Comply with State Law
 

ATTENTION RADIO NEWSROOMS:
AN AUDIO CUT IS AVAILABLE BY CONTACTING THE ATTORNEY GENERAL'S 24 HOUR TOLL-FREE NEWS LINE AT (877) 345-3466, CHOICE #1.

 
Press Release

Survey Report - (HTML Version | PDF Version)

 

 

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

 

Only appeals with full ERISA compliance will ensure maximum reimbursement or crisis turnaround at minimum cost and frustrations.

 

Coding and billing are less than half of the successful reimbursement practice, coding and billing are not appealing and coverage dispute practice. Many coders and billers are wonderful, non-confrontational and very sophisticated individuals, but they might be terrible and counterproductive debaters, and less than ideal legal reasoning and logical thinkers. Many financial executives are hands-free managers in reimbursement divisions.

 

A striking parallel phenomena is also true in the insurance and benefits industry, as described above for medical coding and billing personnel. With the industry compliance tips for the insurance/benefits industry, offered through AAHP in complying with new federal claim regulation, reflected the same problems but provided no practical solutions, the industry is strategically revising the rules of claim processors: "We're taking the claims processors out of the loop. They're good at what they do, but they definitely aren't lawyers. We don't necessarily want them to be making discretionary decisions", said James L. Touse, vice president and associate general counsel for BlueCross BlueShield of Tennessee, at a 2002 policy conference sponsored by the American Association of Health Plans.

 

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....
."

 

That is why, starting January 1, 2003, Aetna and many other insurance companies/ERISA plans have come up with a brand-new programs Appeals Administration Services program, parallel to our certification program, in response to this new ERISA Storm, Real Protections for Health-care Providers and Patients, while health-care providers nationwide are still in sleeping mode pursuing moon project of protections through recycling, reinventing and salvaging the ERISA storm and protection as a result of 28 year ERISA health-care crisis and refinery process.

 

 

The latest Harvard & RAND study for Congress and state legislative debate on Patients' Bills of Rights, conducted by David Studdert and Carole Roan Gresenz, study authors from the Harvard School of Public Health and RAND, funded by federal government, Department Of Labor, and Agency for Health Care Research and Quality, revealed that "little is publicly known about such appeals system", and concluded that "A majority of preservice appeals disputed choice of provider or contractual coverage issues, rather than medical necessity. Medical necessity disputes proliferate not around life-saving treatments but in areas of societal uncertainty about the legitimate boundaries of insurance coverage. Greater transparency about the coverage status of specific services, through more precise contractual language and consumer education about benefits limitations, may help to avoid a large proportion of disputes in managed care."

 

 

A JAMA Editorial commenting this study further supported the conclusion of this study and advanced the right solutions more precisely at New ERISA Claim Regulations: "Regulations issued by the Clinton administration in 2000 were designed to infuse rigor into the appeals process maintained by employer-sponsored health plans covered by the Employee Retirement Income Security Act (ERISA),10 which governs insurance arrangements for more than 150 million workers and their family members. Whether these rules will be vigorously enforced remains to be seen."

 

"......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."

 

 

The updated Harvard & RAND study, funded by the U.S. Department of Labor (DOL), published on June 18, 2003 through Health Affairs, examined the outcomes of nearly a half-million coverage requests in two large medical groups that contract with health plans to deliver care and conduct utilization review, and discovered the urgency and necessity of expertise of ERISA claim procedure specialists. The study concludes the following in its summary and policy implications: "....We found much higher denial rates than those previously reported.....Denials made on contractual grounds—the largest share of denials—may call for both clinical and contractual expertise. Hence, they should ideally be made by personnel who are versant in both areas. There was some evidence of this sort of dual expertise being brought to bear on coverage decisions at the two groups we studied."

 

However these best experts "hired" by Congress and federal government are one step away from the complete discovery and solution. Let us fill in the missing links and connect dots in order to save our health-care system from collapsing and crisis.


First, we identify the controlling force and power in contractual policy coverage denial. The majority of Americans are covered under the employer-sponsored health-care programs in private sectors under ERISA, 80% of the claims and 60% of health expenditures are regulated under ERISA. Each individual ERISA plan offers different coverage and benefits, either self-insured or fully-insured through purchase of insurance from an insurance company. The controlling and governing document for each ERISA plan is Summary Plan Description (SPD), the rule of the game for interpreting each SPD and resolving the disputes on contractual denials is ERISA claims procedure regulations. Therefore the experts from Harvard & Rand study group discovered the importance and necessity of "contractual expertise" but aborted the solution of "contractual expertise" due to "the reasons of size or financial stress, this may be beyond the reach of smaller medical groups that have assumed responsibility for UR".

 

Financial burden and unavailability of this contractual expertise could be the final resolution to their study group to determine if those contractual denials were made by the plan or TPA correctly.

Clinical knowledge and expertise from those medical groups are inherited, but "contractual expertise" is missing badly for policy coverage, Summary Plan Description (SPD) and ERISA Claims Procedure for 80% of health care claims, because such ERISA contractual expertise is nowhere to be found, even for those very experienced health care attorneys and insurance coverage experts, as state law governed insurance policy dispute resolution and ERISA governed claims procedure dispute resolution are quite different, and entire country has never put ERISA into health-care practice. This is why our health-care system failed.

 

Another 2004 new Rand/Harvard study published on February 2004 issue of Annals of Emergency Medicine, "Disputes over coverage of emergency department services: A study of two health maintenance organizations" discovered that 90% of denial in utilization reviews were overturned on appeals, from a stratified random sample of approximately 3,500 appeals of coverage denials lodged by privately insured enrollees between 1998 and 2000 at 2 of the nation's largest HMOs. This study concludes: "The prevalence of ED cases among all appeals reflects disagreement between lay and expert judgments about what constitutes emergency care under the prudent layperson standard. The high rate at which enrollees win these appeals highlights significant disagreement in interpretation of the standard among different adjudicators within managed care organizations (medical groups and health plans). When enrollees fail to challenge denials that would be reversed on appeal, they bear the financial brunt of ambiguities in interpretation of the prudent layperson standard."

 

Who Can Be a Medical Reviewer under ERISA?
(Copyright © 2004 by Jin Zhou,  ERISAclaim.com)


U.S. SUPREME COURT
Docket for 03-83
 

ORAL ARGUMENT TRANSCRIPTS (page 46 0f 49)

  02-1845. Aetna Health Inc. v. Davila 03/23/04

"QUESTION: Mr. Estrada, you can address what you would like but there are three points that have come up during the Respondent's presentation that I'd be interested with a response to.

 

Number one, is it true that the people who make the decisions for your client must be medical doctors in Texas?

 

MR. ESTRADA: Well it is true by virtue of DOL regulations which provide that no claim may be turned down without input from a medical professional in the relevant area"

New Federal Claim Regulation (Final Rule)

  1. "Plans must consult with appropriate health care professionals in deciding appealed claims involving medical judgment." [70268-70269, CFR § 2560.503-1(h)(3)(iii)]

  2. "The term `health care professional' means a physician or other health care professional licensed, accredited, or certified to perform specified health services consistent with State law." [page 70271 CFR § 2560.503-1(m)(7)]  

 

  • "medical doctors in Texas" = MD licensed to practice medicine in Texas for a Texas ERISA case;

  • "a medical professional in the relevant area" = relevant area of state laws in license jurisdiction, scope of practice and relevant local standard of care;

  • "licensed" = licensed by the State Government/licensing board;

  • "to perform" = to practice medicine or health care services in the State;

  • "specified health services" = medical procedures or services being reviewed or denied, instead of file review or insurance coverage reviews services;

  • "consistent with State law" = consistent with State laws where  the health care professional is legally licensed to practice medicine or health care services with respect to state jurisdictions,  scope of license and state local medical standard of care.

 

"The term `health care professional' means, in layman term,  a physician or other health care professional who is at least licensed in your state (and more, board certified too) to practice the specified/specific health services being reviewed or denied of your claims, consistent with your state law jurisdiction, scope of practice and local medical standard of care. Someone who is not licensed to practice the same health care services specified/denied in your claims is not qualified as an "appropriate health care professionals" as defined under ERISA § 2560.503-1(m)(7).

 

Someone who is not licensed in your state to practice "specified health services" but who is merely registered under state or other means (URAC, IME, SSD or Peer Reviews) to do Utilization Reviews (UR) is not qualified as an "appropriate health care professionals" as defined under ERISA § 2560.503-1(m)(7).

 

    U.S. Supreme Court visited ERISAclaim.com in regard to ERISA § 2560.503-1(h) at 11:57:03 AM on Friday, November 21, 2003 for this No. one point. Click here for more coverage of Supreme Court Visiting at ERISAClaim.com.

 

This new Rand/Harvard study warns that "Although the end result for consumers is the same in each of these cases, the messages sent by plans to consumers and medical groups are not. Goodwill payments imply inappropriate use of the ED (notwithstanding the fact that actual merit might not have been assessed). Merit-based overturns, on the other hand, signal an error in utilization review and instruct medical groups about the proper limits of coverage, instructions that medical groups cannot ignore because they must meet the cost of these claims. Hence, merit-based overturns perform a valuable signaling function, akin to the role of judicial precedent in the law. Unless plans invest additional effort in educating utilization reviewers about erroneous decisions for which they are not held financially accountable, goodwill payments of potentially meritorious cases limit opportunities to forge consensus about the limits of the prudent layperson standard and to disseminate accumulated knowledge about its meaning."

 

"Prudent Layperson" Laws Do Not Increase Inappropriate ED Visits (Reuters via Medscape; one-time registration required)

 

"However, some compliance problems did emerge. Some insurers, Hall told Reuters Health, initially deny ED claims and then "quickly reverse" their decision if challenged.

 

"There are two take-home messages for health professionals," Hall said. "One, insurers much less often question the appropriateness of emergency services and two, if insurers initially deny coverage for emergency care, providers or patients should appeal."

 

The impact and enforcement of prudent layperson laws (Mark A. Hall, JD, Annals of Emergency Medicine Online, May 2004 • Volume 43 • Number 5)

[ABSTRACT]  [FULL TEXT] [ PDF]

Importantly, ERISA claim regulation and definition of "claim involving urgent care", 29CFR2560.503-1 (m)(1) - Claims Procedure, has provided governing solutions to "disagreement between lay and expert judgments about what constitutes emergency care under the prudent layperson standard." for these privately insured enrollees. And "Unless plans invest additional effort in educating utilization reviewers about erroneous decisions for which they are not held financially accountable," and ERISA claim regulation and  definition of "claim involving urgent care'', goodwill solution will result in backslash for more disasters in Emergency Department across the country.

 

If 80% of the health-care claim and 60% of health expenditures are governed and regulated by ERISA, ERISA plan's "insurance policy" is controlled by each plan's Summary Plan Description (SPD), and each claim dispute is resolved under ERISA claims procedure regulations, such "contractual expertise", called for by our Rand/Harvard experts, must be from ERISA claim procedure specialists.


Therefore, it is absolutely clear that our nation must provide a solution to health-care crisis by urgently establishing an industry or profession that will possess not only clinical expertise but also, and more importantly, ERISA contractual expertise, ERISA claim procedure expertise.

These three valuable Harvard/Rand studies have pointed out the direction but failed to provide a turnkey practical solution.

 

Now that both Aetna and CIGNA have settled the class-action lawsuits by 950,000 physicians and agreed to process appeals in accordance with ERISA claim regulations for both ERISA claims and non-ERISA claims, and to establish external review boards for Billing and Coding Disputes, Medical Necessity Disputes and Policy Coverage Disputes, in compliance with state external review laws, however external reviews will not be available until internal appeals/ERISA appeals are completely exhausted.

 

 

Aetna Reports First Quarter Results

HARTFORD, Conn.--(BUSINESS WIRE)--April 29, 2004--

 

"-- First-quarter operating earnings, excluding favorable reserve development, of $1.75 per share, compared with Thompson/First Call mean of $1.72, a 31 percent increase over prior-year quarter

-- First quarter net income of $2.28 per share

-- Medical membership increase of 342,000 from year-end 2003"

 

"We also announced several new initiatives to reduce complexity for and improve communications with physicians, including a new information resource, a billing dispute mechanism, and dedicated service centers. And the National Advisory Committee of Practicing Physicians, recently formed as a direct result of our 'new era of cooperation' agreement with physicians, held its first meeting."

 


All other 8 major insurance companies named in class-action lawsuits have refused to settle, even if federal court would rule for physicians, the Aetna and CIGNA settlements will be "as good as it could get" from the rest of insurers and MCO's as evidenced in Aetna and CIGNA settlements with physicians.

 

"Forty states required individuals to first exhaust their health policy’s internal appeals and grievance process before seeking external review." (GAO, September 2003, Page 46)  The health policy’s internal appeals and grievance process = ERISA appeals 80% of the time.

Unless physicians understand and complete ERISA internal appeals, all of those
"a love fest" and "victories" from class-action settlements would mean a fantasy of "a love fest"  to any physicians.

 

From medical coders and billers & insurance claim processors to lawyers for physicians and insurance companies, the occupational and professional gap is a vacuum and too huge to be ignored by both insurance industry and health-care provider industry. A new occupation or profession has to be developed to handle such huge crisis: ERISA health-care Claim Specialists and Department, to bridge the gap FROM medical coders and billers & insurance claim processors TO lawyers.

 

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)."

   Aetna (DOL/ERISA), First Health, Blue Cross Blue Shield are ready to comply with new federal regulation (BCBSIL) (BCBSMI) (BCBSCNY) (BCBSNE) (CareFirstBCBS) & (BCBSAL),  are you ready to get paid faster and fairer?

 

From Aetna's ERISA yesterday (Aetna Video Shows ERISA Patients Mistreated) to Aetna's ERISA today (DOL/ERISA) = Aetna ERISA Actions or intention in compliance and in control.

 

From AMA's ERISA yesterday (The latest Harvard & RAND study) to AMA's ERISA today (JAMA Editorial) =ERISA Actions or Not?

 

That's why physicians, healthcare providers and hospitals must wake up on ERISA now!

 

"Congress library report", "Minneapolis memorandum" and "Phoenix memorandum" should have been sufficient intelligence for executive decision-making on health-care Oct. 11 fact card.

 

In today's progressively worsening health-care and budget crisis since World War II, any health-care executive strategy, without mastering or complying with ERISA, has been proven failing since inception of managed care practice, unless a new health-care reimbursement and compliance model is established and implemented to immediately create a new line of ERISA reimbursement personnels and occupation, "ERISA Healthcare Claim Appeals and Reimbursement Specialists and Departments", no one in this country can stop and survive our failing health care system crisis.

In 2002, our national health-care expenditure has reached $1.55 trillion, 14.9% of GDP, with a predicted 10% increase each year

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

After the failure of every managed care industry model and legislative campaign for Patients' Bill Of Rights, as well as physicians and patients nationwide class actions in managed care reimbursement disputes, a new ERISA regulation, went into effect Jan. 01, 2003, solely designed for regulatory protections and resolutions in most healthcare claim disputes, has been completely ignored by nation's health-care executives as ERISA was in past two decades.

The prevalent industry practice has proven to be risky by increasing service charges, maximum reimbursement can only be achieved through compliance with ERISA, among many other applicable federal and state laws and regulations.

 

AMA has finally noticed the existence and effective date of this new federal claim regulation, as described in its January 20, 2003 online edition of American Medical News: "Federal regulations that dictate rapid turnaround times for health plan claims and appeals quietly went into effect this month, with little noise from the managed care industry."


However AMA has failed, as it did in past 28 years, to practically and meaningfully understand the ERISA and its significance as protections for health-care providers, entire industry has failed to offer any educational programs and occupational trainings to health-care providers in this most important federal law and regulation that governs and regulates up to 80% of health-care claims and 60% of U.S. healthcare expenditures.

 

As reported by AMA as to the time it may take for this new federal claim regulation to take effect in marketplace, Jeffery Mandell, president of the ERISA Law Group in Boise, Idaho, states "it often takes years, even decades, for the marketplace to fully adopt new regulations". Life is too short, our nation's health-care system is going through the worst crisis since World War II and can't afford another 28 years to realize and implement the ERISA regulations. We, everyone including health-care providers, legislators, regulators and insurance companies, should take immediate actions to educate everyone in the system and to implement this new federal claim regulation as we are fighting against terrorists to save our nation's health-care system from worse-than-terror-war crisis.

 

Health-care executives have obligations to save not only their hospitals but also national health-care system from the worst healthcare crisis since WW II, through understanding, complying through implementation of ERISA claim procedure in claim appeals and reimbursement practice.

 

The prevalent industry practice has proven to be risky by increasing service charges, maximum reimbursement can only be achieved through compliance with ERISA, among many other applicable federal and state laws and regulations.

 

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

 

Uninsured patients sue Advocate
Crain's Chicago Business, IL - Nov 19, 2003
A group of former patients on Wednesday sued Oak Brook-based Advocate Health Care System, alleging the hospital chain inflates prices for uninsured patients ...

 

Uninsured patients pay more for medical care
The News-Press, FL - Oct 28, 2003
"... Florida attorney general to take up its cause, accusing hospitals of unfair and deceptive billing practices. The organization found similar hospital billing ..."

 

Critical condition
Sacramento Bee, CA - Oct 26, 2003
"... the US Office of Inspector General ... who replaced Hal Chilton as the hospital's ... in August with the US attorney's ... unnecessary procedures, then fraudulently billing ..."
 

Any traditional and conventional appeals without ERISA COMPLIANCE are "squeaky wheel appeals" for any ERISA claim denials and delays, 80 percent of U.S. Healthcare claims and 60% of U.S. Healthcare expenditure.

Only appeals with full ERISA compliance will ensure maximum reimbursement or crisis turnaround at minimum cost and frustrations.


ERISAclaim.com has provided this nation with a turnkey operational solution with ERISA compliance, to educate everyone on ERISA, coverage and claim procedures, to ensure "Bill Of Rights" for Patients, Providers, Plan Sponsors and Insurers.

We are the only company in today's market providing ERISA healthcare claim compliance practice FOR health-care provider prospects, focusing on one-stop shop services from educating, consulting, publishing and ERISA claims recovery.

 

CALL:  1-630-736-2974

Please e-mail for more details

 

 

U.S. House of Representative Seal

February 5, 2003, H. R. 957 (pdf)
February 5, 2003, H. R. 956 (pdf)

 

Norwood Introduces The Patient Protection & ERISA Clarification Acts

   

Please e-mail for details 

  

Why ERISA Brainstorming

for Healthcare Executives?

 

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.     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.

 

Please e-mail for details 

 

Should You Wait?

    In a letter from Republican Congressional leader, John Boehner, to the Secretary of Labor and insurance/benefits industry, he states that "specifically, we are concerned about provisions in the final rule that go even further than the patients' rights bills passed by the Congress", and he urged DOL to revise and  delay the entire claims regulation.

 

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

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

 

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".

 

A New Diagnosis & Prescription for
Our Nation's Health-care Crisis

 

    Contrary to the popular belief,  our nation's health-care crisis has been truly and mainly caused by the lack of understanding and failing in compliance with ERISA, the federal law regulating about 80% of health-care claims or 60% of health expenditures in the U. S. by both insurance/benefits industry and health-care providers for 28 years, through reckless and fraudulent as well as revengeful, inflationary spiral billings and claim denials that destroyed or foreclosed the faith, hope and ORDER for our nation in health-care quality and cost control, and the lack of meaningful and practical federal administrative enforcement of ERISA claim regulations, because this inflationary spiral skyrocketing increases in managed care claim and denial war behind ERISA shield between health insurers/ERISA plans and healthcare providers have overwhelmingly outnumbered increases in cost of living and national gross domestic products, causing annual double-digit increases in health insurance premiums and skyrocket health-care costs ($1.55 trillion in 2002, 14.9% of the U.S GDP) after every managed care strategy and model failed to contain or control health-care costs in long run despite short-term savings, while entire country has devoted more and more money in litigation, legislation and noncompliant managed care campaign, which practically have solved little or no problem.

 

    In order to resuscitate U.S. Healthcare/managed care from such a critical condition, the strategy and solution must to be a common ground acceptable to all parties involved, instead of hostile and contradictory debate of punitive damage therapy vs. the uninsured coverage in Congress. This common ground for our national health-care crisis is the ERISA Claim Regulations, applicable and existing laws and regulations on the book, originally designed by Congress in 1974 to regulate health-care claim dispute and to avoid fiduciary breach and failures we are facing today.

 

    A new practical and effective solution to saving our nation's health-care system is  to implement ERISA as Congress intended by creating a new occupation or profession, ERISA claim specialists and departments, t0 bridge the gap FROM medical billers and coders & insurance claim processors TO lawyers for both health-care providers and insurance companies/ERISA plans, and to educate everyone in  health-care and employee benefits system, health-care providers and their associations and leaders, IPA's, MCO's, health insurance, employee benefits TPA's and legislators as well as regulators to truly understand ERISA, and comply with existing ERISA's claim procedures and benefits administration rules, to make practical sense for health insurance delivered as employee welfare benefits under ERISA, protecting participants and beneficiaries and safeguarding plan assets through compliance of ERISA laws and regulations by everyone.

 

    How do we know this is the right diagnosis and prescription?

 

Plain and simple, imagine what would happen if the U.S. healthcare superhighway transported $1.55 trillion for 283 million Americans each year without an understanding, without compliance by any one and without the enforcement of any existing laws and regulations governing those 80% of the healthcare claims, 60% of the healthcare expenditures and 163 million Americans under ERISA?

 

The latest Harvard & RAND study for Congress and state legislative debate on Patients' Bills of Rights, conducted by David Studdert and Carole Roan Gresenz, study authors from the Harvard School of Public Health and RAND, funded by federal government, Department Of Labor, and Agency for Health Care Research and Quality, revealed that "little is publicly known about such appeals system", and concluded that "A majority of preservice appeals disputed choice of provider or contractual coverage issues, rather than medical necessity. Medical necessity disputes proliferate not around life-saving treatments but in areas of societal uncertainty about the legitimate boundaries of insurance coverage. Greater transparency about the coverage status of specific services, through more precise contractual language and consumer education about benefits limitations, may help to avoid a large proportion of disputes in managed care.

 

A JAMA Editorial commenting this study further supported the conclusion of this study and advanced the right solutions more precisely at New ERISA Claim Regulations: "Regulations issued by the Clinton administration in 2000 were designed to infuse rigor into the appeals process maintained by employer-sponsored health plans covered by the Employee Retirement Income Security Act (ERISA),10 which governs insurance arrangements for more than 150 million workers and their family members. Whether these rules will be vigorously enforced remains to be seen."

 

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


ERISAclaim.com has provided this nation with a turnkey operational solution with ERISA compliance, to educate everyone on ERISA, coverage and claim procedures, to ensure "Bill Of Rights" for Patients, Providers, Plan Sponsors and Insurers.

 

New Ways to Force Insurance Companies

 to Play by the Rules[PDF]

Reprinted with Permission.  This article was originally published in 2001 December issue of JACA
 Journal of American Chiropractic Association.

 

Fighting ERISA Plan Payment Denials
by Savvy Use of Administrative Appeals
[PDF]

March 2002, Reprinted with Permission from

Managed Care Contracting & Reimbursement Advisor
by Brownstone Publishers, Inc.

 

Challenge UR Company's Qualifications
to Fight Claim Denial
[PDF]

 May 2002, Reprinted with Permission from

Managed Care Contracting & Reimbursement Advisor
by Brownstone Publishers, Inc.

 

Fighting ERISA Plan Payment Denials
by Savvy Use of Administrative Appeals
[PDF]

July 2002, Reprinted with Permission from

Radiology Administrator's
Compliance & Reimbursement Insider

by Brownstone Publishers, Inc.

 

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."

 

EBRI Frequently Asked Questions About Benefits

 

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.”...."

 


 

 

UT Admin Code R590-218. Permitted Language for Reservation of Discretion Clauses.

 

 

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

 

 


 

 

NAIC: UTILIZATION REVIEW AND
BENEFIT DETERMINATION MODEL ACT  PDF file

 


 

NEW Utah State law Mandates ERISA Claim Regulation
(
Copyright © 2004 by Jin Zhou,  ERISAclaim.com)

Did you know that,  effect on March 1, 2004, a NEW Utah State law, UT Admin Code R590-203. Health Grievance Review Process and Disability Claims., has mandated every health insurer and HMO conducting business in the State of Utah to comply with ERISA claim regulation, regardless if the plan is actually an ERISA plan?

 

This is the first state law for health insurance and manage care that mandates and clones ERISA claim regulation at state-level. More and more states are expected to follow.

 

UT Admin Code R590-203. Health Grievance Review Process and Disability Claims.

"R590-203-2. Purpose.


The purpose of this rule is to ensure that health insurer's grievance review procedures for individual and employer health benefit plans comply with the Department of Labor, Pension and Welfare Benefits Administration Rules and Regulations for Administration and Enforcement: Claims Procedure, 29 CFR 2560.503-1, Utah Code Sections 31A-4-116 and 31A-22-629."

 

  (Bulletin) (Utah Code Section 31A-22-629)

 

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

 

Department Of Insurance
Web Sites for All 50 States

 

(Peer Review)
ORDER

Final Order

S T A T E  O F  N O R T H  D A K O T A
MARKET CONDUCT
EXAMINATION
REPORT -
CHIROPRACTIC BENEFITS

NORIDIAN MUTUAL INSURANCE COMPANY
DBA BLUE CROSS BLUE SHIELD OF NORTH DAKOTA

U.S. House of Representative Seal

February 5, 2003, H. R. 957 (pdf)
February 5, 2003, H. R. 956 (pdf)

 

Norwood Introduces The Patient Protection & ERISA Clarification Acts

   
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."

 

American Medical Association: Here's Five Ethical Rules for Managed Care Plans (American Medical Association)

 

 

921 Provider Education and Technical Assistance
931 Transfer of Responsibility for Medicare Appeals
932 Process for Expedited Access to Review
933 Revisions to Medicare Appeals Process
934 Prepayment Review
935 Recovery of Overpayments
937 Process for Correction of Minor Errors and Omissions without Pursuing     Appeals Process
939 Appeals by Providers when there is no Other Party Available
940  

 

Revision to Appeals Timeframes and Amounts
940A Mediation Process for Local Coverage Determinations
952 Revisions to Reassignment Provisions
 

TITLE III—COMBATTING WASTE, FRAUD, AND ABUSE

301  Medicare Secondary Payor (MSP) Provisions

 

CMS: Contact Your Carrier/Fiscal Intermediary

 

via Toll-Free Numbers and Websites -- A listing of the new toll free numbers that CMS has installed at Medicare contractor sites

 

 

 

 

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 10.0

 (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)


Payments Go Under a Microscope (washingtonpost.com)

January 12, 2004

"CareFirst officials said the audit of 2,800 doctors was triggered by an earlier examination of several thousand claims that found 9 of every 10 were inaccurate. "The doctors, we're not saying we don't trust them," said Jeff Valentine, a CareFirst spokesman. "But as President Reagan said a number of years ago: 'Trust, but verify.' "

 

"The largest insurer of all, the federal government, recently estimated that the Medicare program overpaid doctors, hospitals and other health-care providers by $11.6 billion in 2002, according to an audit of 128,000 claims. The audit found many providers submitted insufficient documentation (45 percent), billed for medically unnecessary services (22 percent) and used incorrect codes to describe patient visits (12 percent)."

 

"A larger audit is planned this year. "The digging now is much deeper," said Leslie V. Norwalk, chief operating officer of the Centers for Medicare & Medicaid Services, the government agency known as CMS. "Any dollar overpaid is a dollar too much."

 

"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."

 

 

"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."

.....

"It is the responsibility of an independent reviewer to be alert to fraud and abuse and certainly not to ignore it," said Meehan. "In this case, as the complaint alleges, Ernst & Young kept itself deliberately ignorant of the facts."

United States Department of Health and Human Services: Leading America to Better Health, Safety and Well-Being
 

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"

 

Employers Audit Workers' Health Claims (Wall Street Journal via SFGate.com) & baltimoresun.com - Health plan 'stings' on rise

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."

 

More Employers Checking Eligibility of Dependents Receiving Health Coverage (KaiserNetwork.org)

Employers Check Family Ties to Cut Health Care Rolls (USA TODAY)

"* Ford Motor, which spent $3.2 billion on health care last year, is also looking to recoup some costs from workers. It says intensive audits found 50,000 ineligible dependents since 2000, reducing its health care rolls by about 10%. Some employees have to pay up. The audits will continue. ''We've saved millions of dollars,'' spokeswoman Becky Bach says."

Aetna:  Leading the Fight Against Health Care Fraud [PDF] View as HTML

"Thanks to this highly collaborative relationship, we know how to identify fraud because we know what to look for.

 

Medical Fraud

  1. Unusual provider billing practices.

  2. Discrepancy between the submitted diagnosis and the treatment.

  3. Diagnoses or treatments that are outside the practitioner’s scope of practice.

  4. Claims that are resubmitted with coding changes to gain benefits.

  5. Alterations on claim submissions.

  6. Pressure for quick claim payment."

Excellus BlueCross BlueShield Fraud Recovery and Prevention Efforts Net Over $7.5 Million

 

"The SIU received approximately 1,000 calls to its Fraud Hotline this past year. Tips are also received via e-mails and letters to the company."

"The most common types of insurance fraud include:

  • Billing for services not provided.

  • Billing for higher-level services than those actually performed (known as "upcoding.")

  • Submitting a claim for a fictitious physician or ineligible dependent.

  • Falsifying the identity of a service provider to receive payment for services rendered by a non-covered and/or non-licensed provider. An example of this is billing for a massage at a fitness center as licensed physical therapy.

  • Securing prescriptions for controlled substances that are then re-sold."

 

BlueCross Seeks Consumer Help in Fighting Insurance Fraud

 

Help Fight Fraud - What is Health Care Fraud? (bcbst.com)

 

Labor Department Sues Corporation For Violating Federal Employee Benefit Law (Release Date: 02/02/2004)

 

Effective Corporate Compliance Programs for Health Care Organizations (pdf) (Ernst & Young)

"An executive summary to our 52-page overview of the government's efforts to detect and punish health care fraud and abuse, with guidelines on how organizations can develop an effective corporate compliance program.

Strengthening Ethical Cultures: The Emerging Role of Compliance Programs and Officers in Managed Care Organizations (Ernst & Young)

 

 

United States of America v. Thomas Bruce Vest,
also known as T. Bruce Vest, doing business as Doctors Clinic

 

Appeal from the United States District Court for the Southern District of Illinois, Benton Division. No. 93 CR 30053--J. Phil Gilbert, Chief Judge.

Argued December 13, 1996--Decided June 25, 1997

 

Before Cudahy, Ripple, and Kanne, Circuit Judges

"Second, the Government presented 36 patients who testified that during their visits to the Doctors Clinic, they did not report many of the symptoms and past conditions that Vest recorded on their medical records. On cross-examination, defense counsel used the patients' pre-visit and post-visit medical records to impeach the patients' recollections. If, for example, a patient denied that she reported dizziness to Vest, defense counsel was allowed to cross-examine the witness with medical records showing that the patient reported dizziness either before or after visiting the Doctors Clinic. Third, the Government presented four medical doctors who testified that many of the tests Vest ordered were medically unnecessary."

UW failed to address overbilling, agreed to pay a historic $35 million settlement yesterday (The Seattle Times)

 

"As the University of Washington agreed to pay a historic $35 million settlement yesterday, U.S. Attorney John McKay said his investigation found that Medicare and Medicaid overbilling was common knowledge at the school's medical centers, but the UW did not address the problems."

Table of Contents - Health Care Fraud: Enforcement and Compliance - LawCatalog.com

 

PROSECUTING AND DEFENDING HEALTH CARE FRAUD CASES, WITH 2003 CUMULATIVE SUPPLEMENT (Author(s):  Michael K. Loucks and Carol C. Lam)
 

Text of HHS Semiannual Regulatory Agenda (PDF) (Department of Health & Human Services) 12/13/2004

 

MEDICARE OVERPAYMENTS REACHED NEARLY $20 BILLION IN 2003, NEW SURVEY FINDS (PharmExec)

 

CMS ANNOUNCES IMPROVED EFFORTS TO REDUCE MEDICARE PAYMENT ERROR RATES (12/13/2004, CMS Press Release)

 

Community Benefit Reporting – Guidelines and Standard Definitions for the Community Benefit Inventory for Social Accountability

CHA and VHA Revise Accounting Guidelines for Charity Care.

 

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 
March 30, 2004
New Report Shows HMOs Do Not Adequately Comply with State Law
 

ATTENTION RADIO NEWSROOMS:
AN AUDIO CUT IS AVAILABLE BY CONTACTING THE ATTORNEY GENERAL'S 24 HOUR TOLL-FREE NEWS LINE AT (877) 345-3466, CHOICE #1.

 
Press Release

Survey Report - (HTML Version | PDF Version)

 

 

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."

Overview of Health Savings Accounts With Chart Comparison to Archer MSAs, HRAs and FSAs (PDF) (Miller & Chevalier Chartered)

 

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

 

 

New Federal Reports Highlight Issues in Health Care Quality (The Commonwealth Fund)

Excerpt: "The Department of Health and Human Services has released two reports that represent the first comprehensive national effort to measure the quality of health care in the U.S. and assess disparities in access to and utilization of care."

The National Healthcare Quality Report (http://www.qualitytools.ahrq.gov/)

 

The National Healthcare Disparities Report (http://www.qualitytools.ahrq.gov/)

 

December 03, 2004: NEW CMS STUDY SHOWS MEDICARE, MEDICAID PAID FOR MORE THAN HALF OF ALL SENIOR HEALTH CARE

 

ERISA OVERHAUL OF U.S. HEALTHCARE FOR SURVIVAL

 

"Zhou's Model of Prudent Health Care"

Are All Consultants Corrupt? (Fast Company)

    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

 

 

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

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

 

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".

 


CBO projects 2.7 trillion in deficits (AP - ktvotv3.com)

 

Letter to the Honorable Ted Stevens regarding the preliminary results of CBO's analysis of the President's budgetary proposals for fiscal year 2005, CBO, February 27, 2004

 

Report: US FY03 Budget Gap Much Worse Under Accrual Accounting (Quicken - Feb 27, 2004)

"The official U.S. budget deficit, which is calculated using cash accounting, hit a record $374 billion in fiscal year 2003. That figure becomes a whopping $665 billion under the accrual method the government uses to compile its annual financial report."

Greenspan warns against deficits (CNN - Feb 25, 2004)

 

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

 

HEALTH CARE SPENDING REACHES $1.6 TRILLION IN 2002 (CMS.HHS.Gov)

 

Health Spending Projections Through 2013 (Health Affairs -- Heffler Web Exclusive)

 


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)

 

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."

Problems and Priorities (pollingreport.com)

82% of Americans rank healthcare among their top issues, according to Gallup Poll.

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."

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

 

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


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

 

Law Professor Looks at Criminal Prosecution for HMO Treatment Denial (Prof. John A. Humbach published by the Health Administration Responsibility Project (harp.org))

 

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.

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."

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)

 

 

 

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.

 

 

 

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

 

 

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

 

 

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."

 

$10,600 ERISA Claim

Recent Federal Court Ruling in a Case with $10,600 medical claim, insurance Co. refused to pay, provider made numerous demand for payment in almost one year, but no appeals filed, the court dismissed the lawsuit because provider failed to exhaust administrative remedy, as required under ERISA, by filing ERISA claim appeals.  This situation is so popular in health-care community.

 

 

$37,350 ERISA Claim

Health-care provider alleged medical claims submitted to Aetna for reimbursement, Aetna asserted no receipt of medical claims, no written denials.  Health-care provider failed to present proof of claim submission, claim denial and ERISA claim appeals. This case was dismissed. ERISA health-care claims are handled in federal court, state law is generally not applicable.

 

 

 

PACIFIC COAST HOSPITAL v. AETNA HEALTHCARE

"requesting payment of benefits and/or to discuss the matter in further detail" by hospitals are wasting time and money

 

 

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  

 

 

2002 Employee Health Benefits Survey (Kaiser Family Foundation)

 

Survey: Employee Benefits in Private Industry (2000) (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)

 

Are more workers covered by traditional fee-for-service plans, HMOs, or PPOs?

 

Definitions of Health Insurance Plans and Other Terms (Federal Government’s Interdepartmental Committee)

 

 

 

 

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"

 

 

 

 

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

 

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)

 

 

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."

 

 

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.

UCLA Healthcare -- which includes two hospitals in Westwood and one in Santa Monica -- was forced to borrow $7 million in December from the UCLA chancellor's office to help pay bills."

 

DenverPost.com - Denver Health a model for national health care

 

 

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."

 

 

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."

 

 

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.''

 

 

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)


 

 

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."

 

 

US Department of Justice Seal

USDOJ

 Office of the Deputy Attorney General:

Publications and Documents

 

 

USDOJ: DAG: Corporate Fraud Task Force

 

Federal Bureau of Investigation - Health Care Fraud Unit  

FBI: About the Health Care Fraud Unit

 

VideoVIDEO

 

Link to Site Map

 

Fighting Fraud & Abuse

 
bullet What is Medicare fraud?
bullet How do you recognize it? Fraud Tips
bullet How do you report it?
bullet Recent schemes and scams uncovered by Medicare (alerts)

 

Program Integrity Manual (PIM)

 

 

Examples of Fraudulent Activities

 pdf | word |

 

HHS-Office of Inspector General (OIG)

HHS-OIG-What's New

HHS-OIG-Fraud Prevention & Detection

HHS-OIG - Publications

Advisory Opinion 03-12 PDF (concerning a proposed joint venture between a medical center and a radiology group to own and operate an outpatient open magnetic resonance imaging facility)

 

HHS-OIG-Fraud Prevention & Detection - Fraud Alerts, Bulletins and Other Guidance

 

United States of America v. Thomas Bruce Vest

 

NAIC Antifraud Task Force Activities

 

Table of Contents - Health Care Fraud: Enforcement and Compliance - LawCatalog.com

 

PROSECUTING AND DEFENDING HEALTH CARE FRAUD CASES, WITH 2003 CUMULATIVE SUPPLEMENT (Author(s):  Michael K. Loucks and Carol C. Lam)

 

HEALTH CARE FRAUD AND ABUSE: PRACTICAL PERSPECTIVES, WITH 2003 SUPPLEMENT

 

Health Care Fraud and Abuse Update: Be Careful When Hiring A Business Consultant

 

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

(Press release)

 

GAO: HEALTH CARE Consultants’ Billing Advice May Lead to Improperly Paid Insurance Claims, June 2001

 

 

 

 

Doctor's billing probed (Fredericksburg.com)
"State and federal agents raided the home and office of a Fredericksburg doctor last week, searching for evidence of suspected insurance fraud."

 

Physician Pleads Guilty To Conspiracy To Defraud Medicare and Medi-Cal (6-22-2004) - NEWS RELEASE - United States Attorney Carol C. Lam


A prosecutor accuses hospital of bribing doctors (The Wall Street Journal)

Resurrection billing under fire

Former uninsured patients alleged predatory collections

Chicagobusiness.com
 

Clinton Township firm convicted of overbilling

 

Billing company forced to pay nearly $60,000 to Blue Cross

 

Former official: Improper Medicare claims exceed IG estimate (Government Executive Magazine - 4/20/04)

 

Fraud Recovery and Prevention Efforts Net Over $7.5 Million

 

Chiropractic office owner admits scam over billing (Philadelphia Inquirer)

 

UNITED STATES SETTLES FALSE CLAIMS ACT
CASE AGAINST REHOBOTH CHIROPRACTOR
(DOJ)

 

Suburban Dental Office Manager Gets Prison Time (NBC5.com)

 

Health care group settles with gov't .(Bennington Banner)

"Several lessons were learned through this experience, said SVHC's release. One was that "anytime we acquire a physician practice, we must undertake a thorough review of billing procedures and, if necessary, provide training or retraining to staff to ensure that they understand the reimbursement policies of various payers."

 

8 most common hospital billing errors - Insure your health (MSN Money)

 

FAQ/Glossary, Member Services, Preferred Health Network, PHN Online,( CareFirst BlueChoice, Inc.)

DOL ERISA Talking Points

(BCBSCNY)

 

BCBS 2004 Edu Programs (pdf)

 

BCBS2003 Edu Programs (pdf)


Washington Post Examines Health Plans' Increased Scrutiny of Healthcare Providers' Claims (KaiserNetwork.org)

 

Employers check family ties to cut health care rolls

 

ABCNEWS.com : Huge Medical Insurance Scam Alleged

"Rarely does the FBI discuss an ongoing investigation. But the agency made an exception because this scam is so big. Insurance companies have already been hit with half a billion dollars in claims."

 

CNN.com -Transcripts:

A New Plan to Fight Terrorism? A look at Healthcare Fraud

 

Rent a Patient - Fraud Scheme

(BCBSAL)

 

KSAT.com - Health - 'Rent-A-Patient' Fraud Under Investigation

"UnitedHealth Group alone said it's told the FBI about 300 allegedly fraudulent Southern California centers."

 

State of Wisconsin - DOJ News Release

Lautenschlager Announces Public Alert on "Rent a Patient" Insurance Scams Victimizing Wisconsin Citizens and Businesses

 

Outpatient surgery centers probed for fraud (San Jose Mercury News, CA)

 

'Rent-A-Patient' Fraud Under Investigation
(NBC4.TV, CA)

 

New Boston podiatrists accused of insurance fraud (AP Wire | 03/11/2004)

 

TWO ACCUSED IN NEW BOSTON MEDICAL SCAM

(Tyler Morning Telegraph)

 

Arbour Psychiatric Associates, P.A. Agrees to Pay $148,722 to United States to Settle Health Care Overbilling Claims, Reports.

 

USDOJ: Deputy Attorney General: Publications and Documents - - Health Care Fraud Report Fiscal Year 1998

 

Payments Go Under a Microscope (washingtonpost.com)

 

CMS: Comprehensive Error Rate Testing (CERT) Program

 

(January 15 , 2004)

 

RECOVERY room
(MLive.com)

 

USATODAY.com - Hospitals sock uninsured with much bigger bills

 

A Booster Shot for Uninsured

"Illinois hospitals are hammering out a plan to provide free or discounted care to the uninsured"

 

Hospital group examines plan for free care (Chicagobusiness.com)

""Aggressive collection tactics with uninsured patients cost a non-profit hospital in Urbana its tax-exempt status last month. Illinois Attorney General Lisa Madigan is investigating hospitals’ dealings with the uninsured, and a Chicago alderman is talking about revoking tax breaks for hospitals that limit charity care."

 

Doctor 'scorecards' are proposed (The Wall Street Journal)

 

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

 

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

 

Image conscious: The growing use of doctor-owned scanning centers ... AM News

 

The Status of New Jersey’s Employer-Based Health Insurance

 

Health Insurance Coverage in South Dakota: Final Report of the State Planning Grant Program

 

State of the States 2004

State of the States 2004

 

Practitioners Discuss ERISA Litigation Strategies At ALI-ABA Conference (CCH News & Information Library)

 

Order of Benefit Determination Between Automobile Insurance Personal Injury Protection and Health Insurance* (NJAC 11:3-27)

 

 

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

 

 

 

 

 

 

DOWNLOAD ENTIRE SOURCEBOOK (pdf, 5MB)

 

 

 

 

Agree to terms and conditions

"Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply."

 

CIGNA - Coverage Positions/Criteria
"The terms of a participant's particular benefit plan document [Group Service Agreement (GSA), Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Positions are based. If these Coverage Positions are inconsistent with the terms of the member's specific benefit plan, then the terms of the member's specific benefit plan always control."

 

UnitedHealthcare Medical Policies

"By clicking "I agree," you agree to be bound by the terms and conditions expressed below, in addition to our Site Use Agreement.

UnitedHealthcare medical policies have been made available to you as a general reference resource. When reading these policies you agree that:

Our Medical Policy is not your patient's Benefit Plan.

Your patient's medical benefits are governed and determined by a benefit document, either a Certificate of Coverage or a Summary Plan Description. You should not rely on the information contained in this Web site section to determine your patient's medical benefits.
 

  1. Federal and state mandates and the patient’s benefit document take precedence over these policies.

  2. The patient’s benefit document lists the specific services that have coverage limits or exclusions.


Our Medical Policy does not address every situation and individuals should always consult their physician before making any decisions on medical care."


Medical Necessity: The Gateway to Meaningful Health Care Access (Rosenfeld & Rafik)

 

The Independent Medical Review Program (insurance.ca.gov)

 

 

   
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