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New Federal Health Claims & Appeals Laws & Regulations

for 193 Million Americans

Effective 09-23-2010

©2010, Jin Zhou, ERISAclaim.com

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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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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)

 

ERISAclaim.com -  2010 Claim Denial & Overpayment Dispute Two-day ERISA Appeal Seminars,

 

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

 

New ERISA Appeal Book with 2010 Major Updates  $450  & $150 (Updates only with previous purchase)

 

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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?

 

Contact Us - Reimbursement & Crisis Turnaround Experts

 

Please e-mail for further details

630-736-2974

 

 

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.

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! 

ERISAclaim.com: Unique Services for

Integrated Healthcare Networks

 

 

 

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

 

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

 

 

 

 

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

What You Should Know about Filing
Your Health Benefits Claim (Claims Card)

Filing A Claim For Your Health Or Disability Benefits (PDF)

Patient's Rights Claims Procedure Regulation (Fact Sheet)
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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.

 

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......"

 

 

 

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)

 

Google Search: "Integrated Healthcare Networks"

Results: about 3,370 for "Integrated Healthcare Networks".

 

 

 

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."

 

 

New U.S. Treasury -HSA FAQs Has Grown from 58 to 85,
Under Eight Topic Headings
(Links to U.S. Treasury)

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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)

    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  $$$$$$$$$ERISA$$$$$$$$$$  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

 

ERISA Failure Syndrome

U.S. Healthcare Crisis Trilogy

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

 

ERISA
Medical Killing
ERISA
Medical Inflation
ERISA
Insurance Robbery

Read Making a Killing

?

 

?

?

 

?

GAO-04-312

?
 

?

American Job ExportING!

Mass layoffs up in January 2004

Weirton Steel cancels 10,000

GM: $67.5 billion in 2003

Healthcare Disaster at Fault Verdict Index:

U.S. Government 30%

U.S. Employers & Insurers 30%

Healthcare Providers 30%

Consumers 10%

 

Rx-1  $$$$$$$$$ERISA$$$$$$$$$$  Rx-2

 

The Root of U. S. Healthcare Crisis

Jin Zhou, ERISAclaim.com

The Hearing at Senate Committee on Finance on 3-3-04, [View Video 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)

 

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.

 

Denials + Recoupment = Inflation + Fraud or Cost-Sharing?

Rx = Compliant Denial & Appeals!

Forbes.com: "Roughly one in seven Americans has no health insurance. That hurts HCA Inc. (nyse: HCA - news - people), the largest U.S. hospital chain, which last year wrote off $2.21 billion of revenue because patients couldn't pay their bills."

 

The American Hospital Association (AHA): "Hospitals today are faced with the challenge of managing their limited resources, while continuing to deliver the highest standard of care. According to health care experts, the cost of clinical denials to individual healthcare organizations averages $3.3 million annually. However, many hospitals do not have the resources or the expertise needed to avoid unpaid days at the end of admissions and lead the denial-appeals processes."

 

Payments Go Under a Microscope (washingtonpost.com) "MAMSI and CareFirst recoup overpayments to doctors by making deductions from future reimbursements. Doctors can appeal insurers' decisions. But, in the end, they usually pay up, doctors and insurers agree."

 

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

 

U.S. FILES COMPLAINT AGAINST NATIONAL ACCOUNTING FIRM UNDER FALSE CLAIMS ACT (DOJ Press Release"January 5, 2004 - PHILADELPHIA – United States Attorney Patrick L. Meehan announced today the filing of the Government's complaint against national accounting firm Ernst & Young. According to the complaint, nine hospitals paid Ernst & Young for billing advice – advice which later caused the submission of false claims to the Medicare program."

 

USATODAY.com - Hospitals Sock Uninsured with Much Bigger Bills

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

 

 

 

Medicare Secondary Payer: Improvements Needed to Enhance Debt, GAO Says (U.S. Government Accountability Office)

Excerpt: "Last year, employer-sponsored group health plans ... were responsible for most of the nearly $183 million in outstanding Medicare secondary payer (MSP) debt. MSP debts arise when Medicare inadvertently pays for services that are subsequently determined to be the financial responsibility of another. The Centers for Medicare & Medicaid Services ... administers Medicare with the assistance of about 50 contractors that, as part of their duties, are required to recover MSP debt."

 

Telecare Corp. v. Leavitt

(Fed. Cir. 2005)

 

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.)

 

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)

 

 

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

“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:
  • 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)

 

 

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.”

 

 

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. "

 

Conclusion or Confusion?

© 2005, Jin Zhou, ERISAclaim.com

 

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

 

Based on our comprehensive and diligent study of this new Medicare appeal process, and our extensive experience in ERISA claim procedure practice, and "in view of the wide span of applicability of these rules and the complex, intertwined nature of the affected appeal procedures," [page 2 of 511] it is our conclusion that our nation must recognize and create a new profession, separated from and/or in addition to traditional Coding and Billing personal:

 

"Medicare Appeals Specialist"

 

Guerrilla and weekend training without systematic and quality education will definitely fail in Medicare reimbursement because of its broad requirement and "Authorized Representative" practice with "a waiver of the assignee's right to collect payment...."

 

"Medicare Appeals Specialist" and "ERISA Claims Specialist" will be the crown of US healthcare reimbursement.

 

This is why Congress and CMS created QIC (="Appeal Specialists" with dual and "sufficient medical, legal, and other expertise", § 405.968 (c) (1) [page 394 of 511]) separated FROM and in addition to Medicare Claim Processors (Medicare FI's & Carriers), (Among the major changes required by the BIPA amendments are--......Requiring the establishment of a new appeals entity, the qualified independent contractor (QIC), to conduct “reconsiderations” of contractors’ initial determinations (including redeterminations, [page 15-16 0f 511]).

 

And this is also why Congress enacted ERISA 30 years ago to require "an appropriate named fiduciary of the plan", § 2560.503-1(h) (1), rather than a claim processor or ASO (Administrative Services Only) TPA (Third-Party Administrator) to handle ERISA health claim appeals.

 

Conclusion or Confusion? Your choice and decision.

 

Jin Zhou, ERISAclaim.com, 03/08/2005

 

Medicare New Appeal & Reimbursement Seminars

New Compliance & Challenges

Toll-Free Numbers and Websites for Your Carrier/Fiscal Intermediary

Seminar I

2 days

Seminar II

2 days

Seminar III

2 days

New Medicare Appeal Process & Mandates

v.

Former Process

New Medicare Appeal

 Strategies for

Reimbursement Success

&

  1. Documentation

  2. Fraud And Abuse

  3. Medical Review

  4. National Correct Coding Initiative (NCCI)

  5. more

New Medicare Appeal Laws  Intertwined with($183 million/y)

ERISA Claims Laws

 

CMS 2005 Transmittals
SIZE FILE Adobe PDF Icon Sorted in Decreasing Order  COMM DATE MANUAL SUBJECT IMPL DATE CR NUM
939 kb R35MSP 9/27/2005 PUB 100-05 Updates to the Group Health Plan Identification and Recovery Processes 10/26/2005 4015
94 kb R33MSP 8/12/2005 PUB 100-05 Working Aged Exception for Small Employers in Multi-Employer Group Health Plans (GHPs) 5/20/2005 3768
155 kb R75FM 8/12/2005 PUB 100-06 New Thresholds for 2nd Demand Letter for Physicians/Suppliers 9/6/2005 3932

 

 

Compliance Assistance for Health Plans

 

 

 

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

        Selected links:

Sec. 1002.
Definitions

Sec. 1003.
Coverage

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

Sec. 1140.
Interference with protected rights

Sec. 1141.
Coercive interference

part 7
group health plan requirements

 

 

Code of Federal Regulations

Codified in Title 29 of the Code of Federal Regulations:

Regulations

        Selected links:

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

Claims procedure.

  

 

 

ERISA Laws/Rules

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

 

ERISA in US CODE

 

ERISA Not Insurance
 

Aetna Video Shows ERISA Patients Mistreated

 

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

 

Aetna ERISA Settlemnt with 950,000 MD's

 

Department of Labor

 
"A group health plan is an employee welfare benefit plan established or maintained by an employer or by an employee organization (such as a union), or both, that provides medical care for participants or their dependents directly or through insurance, reimbursement, or otherwise.

Most private sector health plans are covered by the

 Employee Retirement Income Security Act (ERISA). Among other things, ERISA provides protections for participants and beneficiaries in employee benefit plans (participant rights), including providing access to plan information. Also, those individuals who manage plans (and other fiduciaries) must meet certain standards of conduct under the fiduciary responsibilities specified in the law."

 

 

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

   
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