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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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