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Most Highly Integrated Healthcare Networks
Provider-sponsored Organization (PSO)
"Physician-owned-and-operated
HMO's"
Integrated Medical & Insurance
(Rx & Ins)?
What Does an Unanimous
US
Supreme Court Say?
We
provide unique ERISA compliance educational training and consulting to the
highly integrated healthcare systems or networks to maximize the compliance
and to minimize benefits dispute triggered and induced medical malpractice
risks by making the right, ERISA compliant, mixed eligibility decisions
acting through doctors and hospitals from the highly integrated healthcare
systems.
What is so unique with
ERISAclaim.com? We provide ERISA compliance educations and trainings for health-care providers in achieving maximum
reimbursement and at the same time, ERISA compliance for integrated health plans/systems/networks in ERISA claim administration in achieving maximum cost containment and
profitability through compliance.
What is so powerful from ERISAclaim.com? Identifying
the common ground for the "left-hand and right hand" of the integrated
health networks, for prudent plan administration with fiduciary responsibility
strictly in accordance with ERISA claim regulation and the plan document, SPD, combined with health care
provider's compliant appeal process, to minimize administrative costs and
benefits dispute, to truly improve health care quality and patient
satisfactions, with maximum
elimination of administrative waste and fraud.
Integrated Medical & Insurance (Rx &
Ins)?
What Does an Unanimous
US
Supreme Court Say?
Read on, you might be surprised to
know...
Well, IHN's almost will have to
master ERISA claim regulation when providers across the country are about
to embrace ERISA in 2005 and appeal to IHN's in an unprecedented
storm.
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ERISA Seminars for
Healthcare Claim Reimbursement and Denial Management
are slowly,
after 30 years,
but surely
and
finally getting into the mainstream of the
healthcare financial
industry
(pdf, page 2 & page 4), even for
Healthcare Financial Management Association, HFMA, in 2005 for its "32,000
members employed by
hospitals, integrated delivery
systems, long-term and ambulatory care facilities, managed care
organizations, medical group practices, public accounting and consulting
firms, insurance companies, government agencies and other healthcare
organizations." So, you won't be alone or doing something wrong with ERISA. The
question is how you are going to be good or the best at ERISA for denial
management ahead of everyone else in the industry, by finding the best
and taking the best ERISA seminars!
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Most Highly Integrated
Healthcare Networks
Provider-sponsored Organization (PSO)
"Physician-owned-and-operated
HMO"
When doctors and hospitals got
together to offer and operate health plans in today's versatile
health-care market, in competing with health insurers and traditional
managed-care organizations (MCO's), what are the most critical laws that
promote, protect and punish doctors and hospitals in delivery the best
possible quality health care for patients and employers?
When physicians and hospitals
offer health plans, what protections and risks were afforded differently
to physicians and hospitals and insurers?
What federal and state laws must
physicians and hospitals comply with in operating health plans and HMOs?
In addition to Medicare, as
obviously to the most, federal ERISA laws and regulations are the most
critical but confusing to these highly integrated healthcare delivery
system, doctors and hospitals owned and operated health-care plans.
ERISA claim regulation compliance
and medical malpractice uniquely inherited from highly integrated health
networks and systems, according to a unanimous Supreme Court ruling in
Aetna v. Davila.
Integrated (Rx & Ins)
Healthcare Networks?
What Does an Unanimous
US
Supreme Court Say?
On June 21, 2004, an unanimous US Supreme Court
ruled that claim processing (medical judgment & benefits determination) 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, and an insurer operating HMO can not be sued for
medical malpractice but ERISA fiduciary breach, while clarifying
that a physician or hospital owning and operating HMO may be sued for
both medical malpractice and ERISA fiduciary breach.
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ERISAclaim.com -
Supreme Court Managed Care ERISA Watch
An
Unanimous U.S. Supreme Court Ruling in
Managed Care and Medical Malpractice
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."
......
"Pegram cannot be read so broadly.
In Pegram, the plaintiff sued her
physician-owned-and-operated HMO (which provided medical
coverage through plaintiff’s em-ployer pursuant to an
ERISA-regulated benefit plan) and her treating physician, both
for medical malpractice and for a breach of an ERISA fiduciary
duty. See 530 U. S., at 215–216. The plaintiff’s treating
physician was also the person charged with administering
plaintiff’s benefits; it was she who decided whether certain
treatments were covered. See id., at 228. We reasoned
that the physician’s “eligibility decision and the treatment
decision were inex-tricably mixed.” Id., at 229.
We concluded
that “Congress did not intend [the defendant HMO] or any other
HMO to be treated as a fiduciary to the extent that it makes
mixed eligibility decisions acting through its physicians.” Id.,
at 231."
PEGRAM et al. v. HERDRICH
No. 98-1949. Argued February 23,
2000--Decided June 12, 2000
Footnote 8
"......it could be argued that
Carle is a fiduciary insofar as it has
discretionary authority to
administer the plan, and so it is obligated
to disclose characteristics of the
plan and of those who provide services to the plan, if that
information affects beneficiaries' material interests......"
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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.).
ERISAclaim.com:
"We concluded
that “Congress did not intend [the defendant HMO] or any other
HMO to be treated as a fiduciary to the extent that it makes
mixed eligibility decisions acting through its physicians.”
= a HMO owned and
operated by its doctors and hospitals
(such as IHN's) is an ERISA fiduciary when
it makes mixed medical and insurance
coverage decisions (such as "Integreated
Practice).
We
provide unique ERISA compliance educational training and consulting to the
highly integrated healthcare systems or networks to maximize the compliance
and to minimize benefits dispute triggered and induced medical malpractice
risks by making the right, ERISA compliant, mixed eligibility decisions
acting through doctors and hospitals from the highly integrated healthcare
systems.
Please e-mail for further details
630-736-2974
********************************************
Verispan
Releases 2005 IHN 100: Rating of the 100 Most Highly Integrated Healthcare
Networks
Verispan today announced the release of the 2005
Verispan IHN 100, the eighth edition of its annual assessment of the 100
most highly integrated healthcare networks (IHNs). Verispan's report,
regarded as the nation's premier rating system, evaluates IHNs on their
performance and degree of integration.
2005 Verispan's IHN 100
[PDF]
IHC named
nation's top health system
Salt Lake City —For the
fifth time in the last six years, Intermountain Health Care (IHC) has
been ranked as the nation's top integrated health system.
Integration
means that doctors, hospitals, and health plans work together in a
coordinated manner for the benefit of the patient.
Presbyterian Moves Up To No. 7 Most Integrated Healthcare
System ...
SwedishAmerican Health System
Top 25 Integrated Healthcare Networks (IHNs)
[PDF]
(managedhealthcareexecutive.com)
(04/2002)
Results: about 3,370 for "Integrated
Healthcare
Networks".
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ERISA OVERHAUL OF U.S. HEALTHCARE
FOR SURVIVAL
"Zhou's Model of Prudent Health Care"
Are All
Consultants Corrupt? (Fast Company)
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
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Denials +
Recoupment =
Inflation +
Fraud or
Cost-Sharing?
Rx =
Compliant Denial & Appeals! |
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Forbes.com: "Roughly one in seven Americans has
no health insurance. That hurts HCA Inc. (nyse:
HCA -
news
-
people), the largest U.S. hospital chain, which
last year wrote off $2.21 billion
of revenue because patients couldn't pay their
bills."
The American Hospital Association (AHA): "Hospitals today are faced with the challenge of managing their
limited resources, while continuing to deliver the highest standard of care.
According to health care experts, the cost of clinical
denials to individual healthcare organizations averages
$3.3 million
annually. However, many hospitals do not have the resources or the
expertise needed to avoid unpaid days at the end of admissions and lead the
denial-appeals processes."
Payments Go Under a Microscope (washingtonpost.com)
"MAMSI and CareFirst recoup overpayments to doctors by making
deductions from future reimbursements.
Doctors can appeal insurers' decisions.
But, in the end, they usually pay up, doctors and insurers agree."
Hospital Pricing and the Uninsured,
Glenn Melnick, Ph.D.,
"Price
Gouging"
(Subcommittee on Health
Hearing on the Uninsured,
U.S.
FILES COMPLAINT AGAINST NATIONAL ACCOUNTING FIRM UNDER FALSE CLAIMS ACT
(DOJ
Press Release) "January 5, 2004
- PHILADELPHIA –
United States Attorney Patrick L. Meehan announced today the filing of the
Government's
complaint against national accounting firm Ernst & Young.
According to the complaint, nine hospitals paid Ernst & Young for billing
advice – advice which later caused the submission of false claims to the
Medicare program."
USATODAY.com - Hospitals Sock Uninsured with Much Bigger Bills
GM to Report $60B in Future Health-Care Obligations
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CMS News on Wheelchair and
Medical Necessity |
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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
“We are working toward
completing our
overhaul of the Medicare claims
appeals system by October 1,
2005 to better serve Medicare
beneficiaries, providers,
physicians, and other health
care providers.”
"Other
steps that CMS is taking
as part of its
comprehensive overhaul of
Medicare claims appeals
include:
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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.
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Developing a new
appeal-specific data
system that will allow
authorized users to
track individual
appeals in real time.
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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.
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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.
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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."
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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)
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Medicare New Policy:
Medical Necessity in Emergency/Critical Care
On November 5th, CMS issued a modification to
the Medicare Integrity Manual for "Payment
for Emergency Medical Treatment and Labor Act (EMTALA) and new
policy in making emergency room medical decision terminations",
and "Instructs that for an item or service provided
by a hospital or critical access hospital pursuant to section
1867of the Social Security Act (EMTALA) on or after January 1,
2004, FIs must make determinations of whether the item or
service is reasonable and necessary on the basis of information
available to the treating physician or practitioner (including
the patient’s presenting symptoms or complaint) at the time the
item or service was ordered or furnished by the physician or
practitioner (and not only on the patient’s principal
diagnosis). The frequency with which an item or service is
provided to the patient before or after the time of the service
shall not be a consideration."
CMS Manual System
Department of Health & Human Services (DHHS)
Pub. 100-08 Medicare
Program Integrity
Centers for Medicare
& Medicaid Services (CMS) Transmittal 86 Date: NOVEMBER 5, 2005
CHANGE REQUESTS 3437
http://www.cms.hhs.gov/manuals/pm_trans/R86PI.pdf
MEDICARE BENEFICIARIES WILL SOON BE ABLE TO RESOLVE MEDICARE
APPEALS FASTER
October 18, 2004
“We are working toward completing our
overhaul of the Medicare claims appeals system by October 1, 2005
to better serve Medicare beneficiaries, providers, physicians, and
other health care providers.”
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Federal
Employees Health Benefits Program
Aetna
- Chicago
Plan Brochure
2005
What to do in case of emergency:
"If
you need emergency care, you
are covered 24 hours a day, 7 days a week, anywhere in the world.
An emergency medical condition is one manifesting itself by acute
symptoms of sufficient severity such that a prudent layperson, who
possesses average knowledge of health and medicine, could reasonably
expect the absence of immediate medical attention to result in
serious jeopardy to the person’s health, or with respect to a
pregnant woman, the health of the woman and her unborn child.
Whether you
are in or out of an Aetna HMO service area, we simply ask that you
follow the guidelines below when you believe you need emergency
care.
• Call
the local emergency hotline (e.g., 911) or go to the nearest
emergency facility. If a
delay would not be detrimental to your health, call your primary
care physician. Notify your primary care physician as soon as
possible after receiving treatment.
• After
assessing and stabilizing
your condition, the
emergency facility should contact your primary care physician
so he/she can assist the treating physician by supplying information
about your medical history.
• If you are
admitted to an inpatient facility, you or a family member or friend
on your behalf should notify
your primary care physician or Aetna as soon as possible. "
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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 |
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Medicare New Appeal &
Reimbursement Seminars
New Compliance &
Challenges
Toll-Free Numbers and Websites
for
Your
Carrier/Fiscal Intermediary |
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Seminar I 2
days |
Seminar II
2 days |
Seminar III
2 days |
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New Medicare Appeal
Process & Mandates v.
Former Process
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New Medicare Appeal
Strategies for
Reimbursement
Success
&
-
Documentation
-
Fraud And Abuse
-
Medical Review
-
National Correct Coding Initiative
(NCCI)
-
more
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New
Medicare Appeal Laws
Intertwined
with($183
million/y)
ERISA Claims Laws |
CMS 2005 Transmittals
| SIZE |
FILE 
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COMM DATE |
MANUAL
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SUBJECT |
IMPL DATE
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CR NUM
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| 939 kb
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R35MSP |
9/27/2005
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PUB 100-05
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Updates to
the Group Health Plan Identification and Recovery Processes
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10/26/2005
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4015 |
| 94 kb
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R33MSP |
8/12/2005
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PUB 100-05
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Working Aged
Exception for Small Employers in Multi-Employer Group Health Plans
(GHPs) |
5/20/2005
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3768
|
| 155 kb
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R75FM |
8/12/2005
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PUB 100-06
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New Thresholds for
2nd Demand Letter for Physicians/Suppliers
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9/6/2005
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3932
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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. |
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ERISA Laws/Rules |
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ERISA in US
CODE |
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