|
|
|
|
Appeals for
Commonly Seen Medical Claim Denials
with
Superpower
&
Protections from
Compliance with
Federal (ERISA)
&
State Laws
(Utilization &
External Reviews) |
|
|
|
Managed-Care
Medical Necessity Denials? 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.
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 -
Supreme Court Managed Care ERISA Watch
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."
|
|
ERISAclaim.com -
Supreme Court Managed Care ERISA Watch
RUSH PRUDENTIAL HMO,
INC. v. MORAN
“In contrast, the review here may settle a
benefit claim’s fate, but the state statute does not enlarge
the claim beyond the benefits available in any §1132(a)
action. And although the reviewer’s determination would
presumably replace the HMO’s as to what is medically
necessary, the ultimate relief available
would still be what ERISA authorizes in a §1132(a) suit for
benefits. ……
The independent
reviewer has no free-ranging power to construe contract terms,
but instead confines review to the single phrase “medically
necessary.” That reviewer must be a physician with credentials
similar to those of the primary care physician and is expected
to exercise independent medical judgment, based on medical
records submitted by the parties, in deciding what medical
necessity requires. This process does not resemble either
contract interpretation or evidentiary litigation before a
neutral arbiter as much as it looks like the practice of
obtaining a second opinion.”
ERISAclaim.com Note:
Medical Necessity
Reviews Under State Laws & PPO Contract
Independent Medical
Reviews, Utilization Reviews, and PPO Audits Medical Necessity
Reviews, PPO's P4P (Pay for Performance Review per PPO Contract)
under state laws or private contracts can only decide medical
necessity, or “confines review to the single phrase “medically
necessary.”, and plan administrator or fiduciary must decide
coverage for benefits on claims in accordance with ERISA
regulation and each individual plan documents– money for
reimbursement as a final decision. Medical reviewers can NOT
make final decisions on claim payments.
|
Breaking News
950,000 MD's Settled With Aetna & Cigna on ERISA
|
|
Appeal Letter for Plan/Policy Exclusion,
Specific Procedure Exclusion
What You
Should Know about Filing Your Health Benefits Claim
New Federal Claim
Regulation,
effective January 1, 2003, is the best and the most powerful protection
for improper medical necessity denials:
-
"Plans must
consult with
appropriate health care
professionals in
deciding appealed claims
involving medical judgment."
[70268-70269,
CFR § 2560.503-1(h)(3)(iii)]
-
"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)]
-
A Full and Fair Review
with new definitions and protection requires De Dovo reviews on two
appeals by at least four (4) different
people, two (2) different fiduciaries with
ERISA plan, and two (2) different Health-care professionals independent
to the ERISA plan.
[Page 70252-70253,
70268-70269,
CFR § 2560.503-1(h)(3)]
-
Plan must disclose all the
"secrets" under new
definitions of relevant documents with better disclosure obligations,
no more medical necessity secrets, UCR fee
schedules are no longer confidential. [Page
70252 & 70271,
CFR § 2560.503-1(m)(8)
(DOL
FAQ B-5, C17)]
Relying on New Claims
Regulations, Court Orders Plan Insurer to Produce Additional Information
to Claimant
(Employee Benefits Institute of America, EBIA)
Cannon v. UNUM Life
Ins. Co., 2004
U.S. Dist. LEXIS 835 (D. Me. 2004) (PDF)
"ERISA
places the burden of proving an exclusion from coverage in an ERISA-regulated
welfare plan on the plan administrator." Rosalyn Caffey v. Unum Life
Insurance Co
Benefit Denial Overruled Because Plan Failed to
Consult Medical Expert About Benefit Appeal
(Employee Benefits Institute of America (EBIA))
Is Utilization Review Practice a Medical Decision-making?
Is Practice of Utilization Review Performed "Independently" or under
Insurer/ERISA Plan's UR Registration or Legal Authority?
CICIO v VYTRA HEALTHCARE
LAND v CIGNA HEALTHCARE OF FLORIDA
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
|
 
Department of Law
120 Broadway
New York, NY 10271
|
Department of Law
The State Capitol
Albany, NY 12224
|
| |
For More Information:
518-473-5525 |
For Immediate Release
February 10, 2005 |
|
|
|
"Attorney General Eliot Spitzer said
today that 21 health plans operating in New York have agreed
to take new steps to ensure that consumers have the
information they need to intelligently shop for health
coverage and obtain medically necessary care.
Under the agreements, the health plans
have pledged to be more responsive to requests from
consumers for so-called "clinical
review criteria," which is used to determine whether
health care claims will be covered. In the past, health
plans have sometimes failed to
disclose these criteria and other essential coverage
information, discouraging access to needed care......
The clinical review
criteria are extremely
important to consumers with existing medical conditions
because they contain the standards that the health plans use
to determine whether a specific treatment is medically
necessary; if not, coverage is denied and the consumer is
left with the choice of either foregoing medical care or
paying out-of-pocket. The State Managed Care Consumer
Bill of Rights requires health plans to disclose these
criteria to both current and prospective enrollees upon
written request....."
02/10/05
Health Plans Agree to Provide Required Coverage Information
(click for complete official press release)
NEW YORK HEALTH PLANS PARTICIPATING IN
SETTLEMENT
Aetna US Healthcare
Atlantis Health Plan
Capital District Physicians' Health Plan (CDPHP)
CIGNA Healthcare of New York
ConnectiCare of New York
Empire HealthChoice
Excellus Health Plan
Group Health Inc. (GHI)
HealthFirst New York
Health Insurance Plan of Greater New York (HIP)
Health Net of New York
HealthNow New York
Horizon Healthcare of New York
Independent Health Association
MDNY Healthcare
MVP Health Plan
Oxford Health Plans of New York
Preferred Care
United Healthcare of New York
Vytra Health Plans
WellCare of New York
Attachment:
New York Managed Care Consumer Bill of Rights Compliance
Survey
|
|
| |
