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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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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)

 

BCBS Overpayment Class Action Defendants Sought Testimony From The National Expert On Healthcare ERISA Appeal Compliance With ERISAclaim.com - 12-06-2010

 

First National Healthcare PPACA & ERISA Claims Specialist Certification Class Under Health Reform Laws Held For Provider State Association  - 11-22-2010

 

Federal Court Stopped BCBS Overpayment Withholding Claim Practice - Free Webinars On Its Impact For Entire Healthcare Industry - 11-15-2010

 

Breaking News - Federal Court Ruled Against Blue Cross Blue Shield Overpayment Recoupment Practice: “Court's ruling limits Blue Cross' potential recovery”

Federal Court Ruled against BCBSRI's Overpayment Recoupment Practice on October 27, 2010. Relied upon U.S. Supreme Court Ruling in Aetna v. Davila, the Court Ruled That Federal Law ERISA Limits Blue Cross 'Potential Recovery and BCBSRI's State Law Breach of PPO Contract Claim and Fraud Claim Are Completely Preempted by ERISA. BCBSRI’s Post-payment Audit Is a Fiduciary Conduct Governed by Federal Law ERISA Instead of Provider PPO Contract....more

Court Watch: UnitedHealthcare Sued In ERISA Class Action Over Its Overpayment Recoupment Practice

 

© Jin Zhou, President, ERISAcalim.com

08/06/2010

"Hanover Park, IL (ERISAclaim.com) August 06, 2010 - UNITED HEALTHCARE was sued in ERISA class action counterclaims on July 21, 2010 in United States District Court, Southern District of New York, for the alleged ERISA violations in its overpayment practice by patients and providers.

 

This is the third provider ERISA class action lawsuit against Insurers since Aetna was sued in last July and 21 BCBS Entities in last Sept in federal courts over payer’s overpayment recoupment practice, after a federal court ruled in Chicago on BCBS case allowing provider’s ERISA class action claim to proceed, said Dr. Zhou.

" (Read more......)

 

Breaking News from Federal Court

On Overpayment Crisis

 

Insurance News - Pomerantz Haudek Grossman & Gross LLP Announces That Court Permits Provider ERISA Class Action to Proceed Against Blue Cross Blue Shield Companies for Improper Overpayment Demands and Forced Recoupment

 

Pomerantz Haudek Grossman & Gross LLP Announces That Court Permits Provider ERISA Class Action to Proceed Against Blue Cross Blue Shield Companies for Improper Overpayment Demands and Forced Recoupment

 

"NEW YORK, May 25, 2010 (GLOBE NEWSWIRE) -- Pomerantz Haudek Grossman & Gross LLP (the "Pomerantz Firm") today announced that the United States District Court for the Northern District of Illinois upheld claims filed under the Employee Retirement Income Security Act of 1974 ("ERISA") against 22 leading Blue Cross Blue Shield ("BCBS") insurers across the country. The action was filed on behalf of a putative nationwide class of health care providers, as well as the Pennsylvania Chiropractic Association ("PCA"), the New York Chiropractic Council (the "Council"), the Association of New Jersey Chiropractors ("ANJC"), the Florida Chiropractic Association ("FCA"), and the California Chiropractic Association ("CCA"). The suit challenges the Defendants' abusive practices in using post-payment audits and reviews, and improper repayment demands, to pressure providers to repay substantial sums that have previously properly been paid as health insurance benefits for services provided to BCBS subscribers......

 

"This is a landmark decision, with widespread implications for the health care industry," says Jin Zhou, D.C. "Providers finally have a means to fight back against insurance companies for making invalid overpayment demands." Dr. Zhou is a national ERISA consultant who, through his website, www.ERISAclaim.com, and consulting services he offers to providers and plan sponsors, has long advocated the use of ERISA to combat improper post-payment audit activities. "

For a Copy of the Court Ruling

 

PCA et al v. BCBSA et al

May 17, 2010

 

 

 

PORTER v. ANTHEM HEALTH PLANS OF KENTUCKY, INC.

March 18, 2010

United States District Court, E.D. Kentucky, Northern Division, Ashland.

 

A PPO participating provider sued the Anthem for alleged wrongful overpayment recoupment in the state court. "Defendant argues that this case could have been brought under ERISA and is thus subject to federal jurisdiction. The Court agrees."

 

The court mainly relied upon the U.S. Supreme Court unanimous landmark decision in Aetna v. Davila, and ruled that PPO overpayment recoupment dispute is 100% ERISA business, not PPO business at all.

 

This is the latest and the first federal court ruling for skyrocketing overpayment crisis in U.S. healthcare system with a potential of $6 trillion in overpayment dispute market. The provider class action lawsuits under ERISA are expected to explode in 2010.

 

ERISAclaim.com is the only compliance consultant and publisher with ERISA compliant Appeals Books and systems to effectively assist providers in appealing the alleged overpayment demand and recoupment under ERISA:

New Free Webinars Announced to Discuss the Latest Federal Court Overpayment Lawsuit Ruling and New Obama Health Laws for the Skyrocketing $6 Trillion Overpayment Recoupment Market 03-29-2010, Hanover Park, IL

 

The New ERISA Overpayment Appeals And Anti-Fraud Services Announced For Healthcare Providers Through ERISA Appeals And Anti-Fraud Compliance 02-08-2010, Hanover Park, IL

 

ERISAclaim.com: 2010 Appeal Books & Systems for Maximal Reimbursement by Compliance

 

PORTER v. ANTHEM HEALTH PLANS OF KENTUCKY, INC.

March 18, 2010

United States District Court, E.D. Kentucky, Northern Division, Ashland.

 

"In addition, Plaintiffs' claim sounds in ERISA. Absent ERISA, there would be no obligation between the parties. Of note in this regard is United States Supreme Court decision in which participants in an ERISA plan sued the plan administrators in tort, alleging injury arising from the administrators' decisions to deny coverage for certain treatments. Aetna Health, Inc. v. Davilla, 542 U.S. 200 (2004). The Supreme Court rejected the Plaintiffs' argument that the action sounded in state tort law, finding that liability only exited because of the ERISA plans that bound the parties. Id.


As in Davilla, that Porter and his practice have a provider contract with Anthem does not, in and of itself, create an independent legal duty for Anthem to make payments to Porter. What is payable, and, more importantly, what is not is defined by the terms of the benefit plans and, thus, governed by ERISA."

Pomerantz Files Class Action Against Blue Cross Blue Shield Association

 

Sept. 10, 2009

"Pomerantz filed a class action lawsuit against the Blue Cross Blue Shield Association ("BCBSA") and 22 leading BCBS insurers across the country on behalf of a putative nationwide class of health care providers, as well as the Pennsylvania Chiropractic Association ("PCA"), the New York Chiropractic Council (the "Council"), and the Association of New Jersey Chiropractors ("ANJC"). The suit challenges the Defendants' abusive practices in using post-payment audits and reviews, and improper repayment demands, to pressure providers to repay substantial sums that have previously properly been paid as health insurance benefits for services provided to BCBS subscribers."

For a copy of the BCBSA Complaint, click here

 

 

 

Breaking News - Federal Court Ruled Against Blue Cross Blue Shield Overpayment Recoupment Practice: “Court's ruling limits Blue Cross' potential recovery”

Federal Court Ruled against BCBSRI's Overpayment Recoupment Practice on October 27, 2010. Relied upon U.S. Supreme Court Ruling in Aetna v. Davila, the Court Ruled That Federal Law ERISA Limits Blue Cross 'Potential Recovery and BCBSRI's State Law Breach of PPO Contract Claim and Fraud Claim Are Completely Preempted by ERISA. BCBSRI’s Post-payment Audit Is a Fiduciary Conduct Governed by Federal Law ERISA Instead of Provider PPO Contract....more

 

"Overpayment" Refund Request Response & Appeals

 © 2003 - 20010  Jin Zhou, ERISAclaim.com

(See below for the laws governing your overpayment dispute)

 

We provide special onsite consulting and seminar services if you have a significant overpayment dispute.

 

If you are under a PPO audit or any payment related audits or reviews, we can help you in exercising your appeal rights to avoid unnecessary nightmares and financial losses.

 

We provide providers with a very unique overpayment appeals program with combined ERISA appeals and comprehensive anti-fraud initiative on CCI compliance to avoid up-coding and unbundling allegations, medical necessity denials to challenge payer's PPO medical policies, and more on fraud & abuse prevention to survive commonly seen audits and reviews with compliance & appeals defense.

 

Please call or email for more details. We can be  reached at (630)-808-7237 by phone or by email at  ERISAclaim@aol.com

 

 

ERISAclaim.com Press Release

The New ERISA Overpayment Appeals And Anti-Fraud Services Announced For Healthcare Providers Through ERISA Appeals And Anti-Fraud Compliance 02-08-2010, Hanover Park, IL

"In Light of Increasing Frivolous And Debilitating Overpayment Refund Demand From Payers, ERISAclaim.com Announced The Nation’s First ERISA Overpayment Appeals and Anti-Fraud Services to Help Healthcare Providers to Effectively Appeal All Alleged Overpayment Denials in Essence of Retrospective Benefits Denials and Increase Fraud and Abuse Prevention ‘Compliance, As Federal Law ERISA Governs All Denials of Benefits From ERISA Plans and Prohibits Fraudulent Interference with ERISA Rights"

 

"ERISAclaim.com’s ERISA Overpayment Appeals and Anti-Fraud Services will assist healthcare providers, on-site or off-site, with ERISA assessment of the overpayment refund demand (retrospective EOB), CCI compliance, PPO Medical Policy and Documentation compliance as well as the assessment of potential provider claim risks. ERISAclaim.com will assist providers with timely appeals, based on the correct and truthful facts of the claims, ERISA claim regulation, relevant plan coverage documents and plan Summary Plan Description (SPD). ERISAclaim.com will also provide specific education on healthcare fraud and abuse prevention, Corporate Compliance Initiative in billing, coding and documentation, as a compliance and risk management for healthcare providers. When necessary, ERISAclaim.com will refer to the healthcare attorneys of the client choices for further professional guidance and representations, in addition to the litigation support services provided by ERISAclaim.com.com. The costs for these ERISA Appeals and Fraud Prevention Services will depend upon the nature and size of the overpayment refund demands and claims."

For Complete Copy of this Press Release, Click Here

 

 

Lexology - Notes on the National Summit on Health Care Fraud

Reed Smith LLP, USA

 

February 1 2010

"Last week, in my capacity as president of the American Health Lawyers Association, I attended the first National Summit on Health Care Fraud, a joint undertaking by the U.S. Department of Health and Human Services and the U.S. Department of Justice. The conference brought together private sector leaders, law enforcement personnel, and health care experts as part of the Obama Administration’s coordinated effort to fight health care fraud. This was the first national gathering on health care fraud between law enforcement and the private and public sectors."  

STOP Medicare Fraud - U.S. Department of Health & Human Services and U.S. Department of Justice (http://www.stopmedicarefraud.gov)

"National Summit on Health Care Fraud

U.S. Department of Health and Human Services Secretary Kathleen Sebelius and Attorney General Eric Holder convened a “National Summit on Health Care Fraud” on Thursday January 28, to bring together leaders from the public and private sectors to identify and discuss innovative ways to eliminate fraud, waste and abuse in the U.S. health care system. The National Summit is the latest initiative of the Health Care Fraud Prevention & Enforcement Action Team (HEAT)."

 

 

 

ERISA Laws are the Best Protections to Providers

for the Overpayment Disputes


We offer special appeal services under ERISA to all providers. Our goals are to appeal to the plan, to educate and persuade the health plan, based on the facts and governing laws, to resolve the overpayment dispute. In most cases, our clients paid nothing back and received letters of apologies from the TPA and ERISA plans.

 

If you are facing sigificant and frequent overpayment challenges, please contact us at 630-736-2974 or email your questions to ERISAclaim@aol.com

 

 

NBC 10 Breaking News:

Overpayment - FBI - Class Action

"Biggest Fraud in US History"

NBC10 Video

Blue Cross sues doctor over payments 


NARRAGANSETT, R.I. -- Just two days after a Narragansett doctor leveled strong accusations against Blue Cross & Blue Shield of Rhode Island, he learned he was being sued. Blue Cross filed a $100,000 lawsuit against Dr. Jay Korsen for damages caused by his going public with his complaints. - turnto10.com - Jun 19, 2009

 

Doctor claims Blue Cross withheld payments 


http://www.turnto10.com/jar/news/local/article/doctor_says_bcbs/14643/
A local chiropractor says he was strong armed by Blue Cross & Blue Shield of Rhode Island. The Narrangansett doctor says Blue Cross withheld money from him and he charges them with intimidation. -  turnto10.com - Jun 17, 2009

 

Pomerantz Files Class Action Against Blue Cross Blue Shield Association

 

Sept. 10, 2009

"Pomerantz filed a class action lawsuit against the Blue Cross Blue Shield Association ("BCBSA") and 22 leading BCBS insurers across the country on behalf of a putative nationwide class of health care providers, as well as the Pennsylvania Chiropractic Association ("PCA"), the New York Chiropractic Council (the "Council"), and the Association of New Jersey Chiropractors ("ANJC"). The suit challenges the Defendants' abusive practices in using post-payment audits and reviews, and improper repayment demands, to pressure providers to repay substantial sums that have previously properly been paid as health insurance benefits for services provided to BCBS subscribers."

For a copy of the BCBSA Complaint, click here

 

Breaking News: Court Watch - ERISA Completely Pre-empts BCBSRI Overpayment PPO Claims and Fraud Claims and ERISA Limits Blue Cross' Potential Recovery

 

BCBSRI v. JAY S. KORSEN and IAN D. BARLOW

 

UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF RHODE ISLAND

10/27/10

[page 16-17 of 19]

 

"Consequently, the Court holds that Blue Cross' Count I for breach of contract, alleging that Defendants breached the Provider Agreements by submitting claims using improper CPT codes and submitting claims for services that were inappropriate or not medically necessary, and Count II for fraud are completely preempted by ERISA. The Court converts these claims to a federal ERISA § 502 (a) (3) claim."

 

"Though the Court's ruling limits Blue Cross' potential recovery, this holding is consistent with the legislative aims identified by the Supreme Court in Davila"

 

 

Pomerantz Files Class Action Against Blue Cross Blue Shield Association ("BCBSA") and Related BCBSA Entities

Reuters, Thu Sep 10, 2009 6:11pm EDT

 

CHICAGO--(Business Wire)--

"Pomerantz Haudek Grossman & Gross LLP today announced that it and co-counsel Buttaci & Leardi, LLC filed a class action lawsuit against the Blue Cross Blue Shield Association ("BCBSA") and 22 leading BCBS insurers across the country on behalf of a putative nationwide class of health care providers, as well as the Pennsylvania Chiropractic Association ("PCA"), the New York Chiropractic Council (the "Council"), and the Association of New Jersey Chiropractors ("ANJC"). The suit challenges the Defendants` abusive practices in using post-payment audits and reviews, and improper repayment demands, to pressure providers to repay substantial sums that have previously properly been paid as health insurance benefits for services provided to BCBS subscribers.

 

......In making the appointment, the Court stressed the significant role Pomerantz had played in a $249 million settlement of its UCR class action against Health Net, stating that the Court had "similarly appointed Pomerantz to be Plaintiffs` spokesman to the Court in the Health Net litigation because the Court found D. Brian Hufford, Esq. to be the attorney most capable of presenting Plaintiffs` position in a clear and concise manner." In re Aetna UCR Litig., 2009 Dist. LEXIS 66853, *8 n.4 (D.N.J. July 31, 2009)."

For a copy of the BCBSA Complaint, click here

 

Pomerantz Files Class Action Against Aetna (News from Pomerantz)

 

For a Copy of the Official Complaint, click here

 

Pomerantz Files Class Action Suit Against Aetna On Behalf of Healthcare Providers to Challenge Abusive Post-Payment Audit Practices (GlobeNewsWire, press release)

 

"NEWARK, N.J., July 29, 2009 (GLOBE NEWSWIRE) -- Pomerantz Haudek Grossman & Gross LLP today announced that it and co-counsel Buttaci & Leardi, LLC, have filed a class action lawsuit against Aetna, Inc., and its various health insurance subsidiaries on behalf of a putative nationwide class of health care providers, the Association of New Jersey Chiropractors ("ANJC") and the New York Chiropractic Council ("NYCC"). The suit challenges Aetna's abusive practices in using post-payment audits, with false allegations of fraud, to pressure providers to repay substantial sums that have previously properly been paid for providing services to Aetna subscribers.

The action alleges that Aetna's post-payment audit process violates the Employee Retirement Income Security Act of 1974 ("ERISA"), in that its repayment demands are retroactive determinations that particular services are not covered under the terms of Aetna's health care plans, but without any of the appeal or other protections otherwise available under ERISA for both self-funded and fully insured health care plans offered through private employers. The complaint further alleges that both the post-payment audit process and the pre-payment claim review process employed by Aetna to strong-arm chiropractors into unfavorable settlements violate the Racketeer Influenced and Corrupt Organizations Act ("RICO"). In addition to challenging the process by which Aetna pursues and applies its audits, the complaint also challenges numerous clinical policy bulletins of Aetna, which are used to deny services retroactively without adequate basis or clinical support."

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

BCBSA News, June 30, 2009

Blue Cross And Blue Shield Companies' Anti-Fraud Efforts Recover $350 Million In 2008

"WASHINGTON – Blue Cross and Blue Shield companies' anti-fraud investigations resulted in overall savings and recoveries of nearly $350 million in 2008, an increase of 43 percent from 2007, according to data released today by the Blue Cross and Blue Shield Association (BCBSA) National Anti-fraud Department (NAFD).  From 2007 to 2008, the number of cases opened increased nearly 34 percent, and the closed cases increased about 43 percent."

AMNews: July 6, 2009. Tennessee Medical Assn. sues collections firm
Health Research Insights has contacted physicians in several states this year trying to collect alleged overpayments.

 

For A Copy of TMA v. HRI Lawsuit, click here
 

AMNews: May 18, 2009. State medical societies strategize against collector
Legal action is one option against Health Research Insights.
 

AMNews: May 11, 2009. Company stops tapping physicians for 'overpayments'
Doctors protested self-insured Georgia-Pacific's attempt to collect refunds of suspected claims upcoding.
 

AMNews: April 13, 2009. Self-insured companies going after doctors to recover 'overpaid' claims
There is no clear time limit on how far back ERISA-protected companies can go to recoup money. One company is turning that into a business.

 

Overpayment Demand Letter from HRI:

"Dear Health Care Professional,

 

......You must take action as outlined in items (1) or (2) above, in order to ensure compliance with the Employee Retirement Income Security Act of 1974 (ERISA). ERISA is the federal law that, among other things, governs health benefit plans in private industry. Investigation of potential ERISA violations is given to the United States Secretary of Labor pursuant to sections 504 and 506 as amended by the Comprehensive Crime Control Act of 1984 and enforced by the US Department of Labor.

 

In the event HRI is not contacted by you or your designee, a Complaint may be filed with the Employee Benefits Security Administration (EBSA). You may view additional information at (www.dol.gov/ebsa)."

Physicians Strike Back At Employers' Collection Firms ( BNET Healthcare Blog | BNET)

"In the most recent clash, the Tennessee Medical Association has sued Health Research Insights (HRI), a Franklin, TN-based firm that has sent collection letters to physicians in Georgia, Kentucky, Tennessee and Texas. Other defendants in the suit include the Metropolitan Government of Nashville and Davidson County, TN, and Nashville’s Board of Education, which runs a self-insured plan for school employees. Blue Cross and Blue Shield of Tennessee, the plan’s administrator, is also named in the suit, although the insurer disavows any relationship with the collection firm.

 

The suit, which alleges fraud, says that HRI keeps 40 percent of whatever it collects. The TMA wants a court to enjoin HRI from making any further efforts to collect from physicians. An earlier protest by the Georgia Medical Society against HRI’s work on behalf of Georgia Pacific led to a suspension of those activities."

Employment-Based Health Coverage and Health Reform: Selected Legal Considerations (PDF) (U.S. Congressional Research Service)

"It is estimated that nearly 170 million individuals have employer-based health coverage. As part of a comprehensive health care reform effort, there has been support (including from the Obama Administration) in enacting comprehensive health insurance reform that retains the employerbased system. This report presents selected legal considerations inherent in amending two of the primary federal laws governing employer-sponsored health care: the Employee Retirement Income Security Act (ERISA) and the Internal Revenue Code (IRC)."

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

 

 

2007 Claim Denial & Overpayment Dispute

ERISA Appeal Seminar

 

07/28/2007 - 8 hours (8 am -12 pm & 1 pm - 5 pm)

 

Northside Hospital Interchange Building

 Classroom No. 419

5780 Peachtree Dunwoody Road, Suite 400

Atlanta, GA 30342 

Click here for Nearest Hotels

 

$299 - $600

Call: 630-736-2974

For more info: http://www.erisaclaim.com/seminars.htm

E-mail Your Questions to ERISAclaim@aol.com

 

How to Sign up?

 

               Our new 2007 ERISA Seminars can be enrolled by

 

1. Calling 630-736-2974

 

2. Download, fax a completed Registration Form to 630-736-1439

 

3. Online Secured registration.

 

Maximizing Healthcare Claim Reimbursement

Problem Oriented Appeals under ERISA

 

 

 

New 2007 ERISA Appeal Major Updates

ERISAclaim.com

04/06/2007

 

New Denial Crisis Demanding for New Solutions

for Your Reimbursement Problems

 

               In 2007, healthcare providers are facing unprecedented reimbursement crisis for healthcare claim denials, delays and "overpayment" recoupment as well as managed care PPO audits.

 

               Several years ago, most health care providers were seeing class actions against insurance companies and managed care entities by 950,000 physicians across USA after terribly failed political actions of "Patient's Bill of Rights" campaign for eight years, and desperately hoping to see some positive changes.  In last several year those class actions were either settled or dismissed by federal court.

 

               Do you see any major positive changes for your reimbursement?

 

               No!

 

               Now in 2007, the game is totally different.  More and more healthcare providers are the target of healthcare fraud lawsuits and investigations, PPO fraud and abuse audits, and more detrimentally harmful to financial bottom line for many healthcare providers and facilities. We have been experiencing more and more Volcano type of PPO audits and tornado type of overpayment recoupment crisis from payers withholding subsequent claim payments for millions of dollars, while no federal or state agency seemed to have jurisdictions for healthcare provider’s Katrina crying for justice, and while state government declined to intervene because of ERISA preemption and federal government refused to investigate because of alleged provider network contract agreement dispute, but healthcare providers on behalf of your patients received no payments or little payments for already approved claims as a result of "overpayment" recoupment by the payers.

 

Most Comprehensive Research and Analysis from US Supreme Court Rulings

 

               US supreme court unanimously ruled on June 21, 2004 that ERISA, a federal law, controls and governs your problems in managed care crisis if you want any money from the employer sponsored health plans.

 

Most Comprehensive, Advanced And Practical Appeal Letters For “Overpayment Recoupment” Due To PPO Audits And Medical Necessity As Well As Poor Documentation For Both Self-Funded ERISA Plan And Fully-Insured ERISA Plan

 

               Our new 2007 major updates provide you with most powerful protections and advanced appeal letters based on all of US Supreme Court recent rulings on managed care reimbursement, ERISA state law and PPO preemption, state law medical review preemption, and every type of practical arguments used by payers in withholding and recouping benefits payment from healthcare providers for those already approved benefits claims.

 

Latest Federal Court Ruling on Disallowing Health Plan Recovery or Recoupment against Healthcare Providers

 

               Two new federal court rulings on overpayment and state law prompted pay preemption relied upon most recent US Supreme Court rulings, in addition to our 2006 updates in this area.

 

Latest Federal Court Ruling on Definitive ERISA Preemption of State Prompt Pay Law.

 

               For years, federal and state regulators, legal and health care experts, health care providers and insurance companies are not certain if federal law ERISA preempts state Prompt Pay Laws, now federal court has ruled clearly that ERISA definitely preempts state prompt pay laws based on analysis of Supreme Court recent rulings.

 

97.96% Claims of United Healthcare Lawsuit in These Case Were ERISA Claims

 

               You will be also surprised to learn that in this provider lawsuit against United healthcare for wrongful denial of benefits claims.

 

"Plaintiffs lawsuit centers around 295 claims for services rendered by Schoedinger to patients covered by United healthcare plans. 289 of these claims qualify as Employee Welfare Benefit Plans under ERISA, and 6 involve non-ERISA plans.5 268 of the ERISA claims surround self-funded or self-insured health plans, in which the employers are financially liable for any benefits due and United serves only as the plan administrator and claims processor. 21 of the ERISA claims and all of the non-ERISA claims involve health plans that are fully insured by United. For these 27 claims, United is financially responsible for the benefits due to plan participants and serves as the plan administrator and claims processor."

 

No PPO Participation, No Checks to Non-PPO Providers, but ERISA Laws Protect You

 

               Because certain major payers are no longer sending reimbursement checks to healthcare providers who were not participating in the network, we have thoroughly researched federal law, ERISA, and developed a most powerful but straightforward action plan package based on specific federal ERISA regulation and requirements for healthcare providers to receive reimbursement checks directly from the insurance payers.

 

New Federal Government Guidelines on Filing Benefits Claims and Appeals

 

               Our 2007 major updates also include latest federal government, DOL, guidance on filing healthcare claims and appeals

 

New Federal Government Guidelines on Pre-Existing Condition Denials and Protections

 

               Our 2007 major updates also include latest federal government, DOL, guidance on filing healthcare claims, appeals for pre-existing condition protections.

 

               Our U.S. employment market in modern society, divorce, relocation and adoption as well as newborn babies have caused countless mysterious claim denials and delays due to mysterious “additional information requesting” by payers from patients and health care providers, but healthcare providers can never find out what exactly addition information the payers are looking for.  These confidential information is not about privacy compliance but pre-existing condition investigation, also governed by HIPAA, money part of HIPAA regulation.

 

               HIPAA pre-existing condition regulation was never fully understood by healthcare providers, as HIPAA is part of ERISA regulation.

 

               If you want to get paid quickly and accurately for 90% of your non-Medicare claims from patients obtained health insurance from employment in private sectors, you must understand and follow published federal government guidelines.

 

How to Order?

 

               Our new 2007 ERISA Appeal Updates can be ordered for $95 by those who have previously purchased our ERISA Appeal CD Book and Systems, and these updates cannot be separately purchased without prior purchase of ERISA Appeal CD Book and Systems for $450. However Our new 2007 ERISA Appeal Updates is free to those who have purchased ERISA Appeal CD Book and Systems in past 30 days from 04/07/2007.

 

               You may place your order from our website, www.ERISAclaim.com  on page of Appeal Books and Systems at http://www.erisaclaim.com/products.htm

 

               You may also call us at 630-736-2974 for a phone order or any questions

 

 

Vacca et al v. Trinitas Hospital

Nov. 14, 2006

UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF NEW YORK

 

ERISA Does Not Authorize or Provide Remedy for
Plan's Overpayment Recoupment Actions
Against Healthcare Provider

 

We provide healthcare providers with in-house consulting and turn-keys programs
if you have big claims or a lot of  overpayment troubles

 

Call: 630-736-2974

Email: ERISAclaim@aol.com

www.ERISAclaim.com

 

Comments from other legal websites

Health Plan Lawsuit Watch (aishealth.com)

Health Care Managed Care Lawsuit Watch (Crowell & Moring LLP)

Health Plan Law - ERISA Group Health Plan Administration » 2006

"Plan’s Suit Against Hospital For Overpayment Dismissed Based Upon Knudson Analysis"

 

New 2006 Appeal Letters (10/13/2006)
 

ERISA Appeal for Overpayment Refund Request due to Medical Necessity and New PPO Hearing

 

In accordance with U.S. Supreme Court decision in Aetna Health Inc. v. Davila on 06/21/2004, “Medical necessity” dispute or denial and subsquent overpayment request, is an ERISA plan retrospective administrative remedy, and any non-ERISA “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),......"


New 2006
Appeal Letters (10/04/2006)

 

Due to the increasing Katrina style of  plan OverPayment Recoupment or Recovery denials, when plans withhold or reduce countless subsequent or future plan approved claim payments by alleging recoupment or recovery for previously overpaid claims to providers, we have added to our ERISA Appeal Book & System the most powerful ERISA appeal letter (OverPayment Recoupmet Appeal 2006) based on all applicable U.S. Supreme Court rulings, 2432 Coercive or Fraudulent Interference with ERISA Rights -- 29 U.S.C. 1141 and new ERISDA claim regulation as well as our practical experience and knowledge in ERISA appeal practice.

 

New 2006 Appeal Letters (09/28/2006)

 

We have added two new and updated appeal letters to our ERISA Appeal CD Book for increasing overpayment refund requests and disputes from health plans and commercial collection companies.

 

Our new and updated appeal letters are based on ERISA claim regulation on denials-adverse benefits determination, two new U.S. Supreme Court rulings in Aetna Health Inc. v. Davila on 06/21/2006  and Sereboff v. Mid Atlantic Medical Services on 05/15/200 as well as federal “Fair Debt Collection Practices Act”.

 

Pricing for copyrighted update letters: Free to anyone who purchased our ERISA Appeal CD Book in past 60 days (please email us for free password). $35 for anyone who purchased our ERISA Appeal CD Book prior to past 60 days. Who may use our online secured order page to pay for your order and password, then download the letters from our "Appeal Book & System Page". We do not sell these appeal letters separately from our ERISA Appeal CD Book ($450).

 

 

"Overpayment" Refund Request Response & Appeals

 © 2003 - 20010  Jin Zhou, ERISAclaim.com

 

 

Rx-1  $$$$$$$$$ERISA"Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance
$$$$$$$$$$  Rx-2

Are All Consultants Corrupt? (Fast Company)

950,000 MD's Settled With Aetna & Cigna on ERISA

 

 

Managed-Care "Over Payment" Crisis? What Does an Unanimous US Supreme Court Say?

 

On June 21, 2004, an unanimous US Supreme Court ruled that claim processing (retrospective negative benefits determination & recouping)  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."

 

Is An Overpayment Refund Dispute with or from An ERISA Plan Payer Still an ERISA Claim, and Subject to ERISA Jurisdiction of Federal Court and ERISA Claim Regulation?

 

YES.

 

In PERALTA V HISPANIC BUSINESS, the Ninth Circuit has explained that common law claims do not “relate to” an ERISA plan when:

  1. “the “adjudication of the claim required no interpretation of the plan”,

  2. "no distribution of benefits”, and

  3. 3.no dispute regarding any benefits previously paid”.

 

Overpayment recoupment and overpayment refund request dispute are extremely popular today for both health-care providers and health-care plan payers as well as TPA or benefits recovery industry.

 

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

32 pages. 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.)

 

SLATER HEALTH CENTER, INC. v. UNITED STATES; BLUE CROSS & BLUE SHIELD OF RHODE ISLAND

 

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)

 

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

 

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."

[doc] Press Release: Horizon Agrees To Temporarily Halt Efforts To Recover Money From State’s Cardiologists As A Result Of MSNJ Lawsuit, 12-09-2004

Assemblyman Neil Cohen's Letter (pdf)

 

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."

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. ...."

 

There has been a great deal of confusion as to what Law and regulation are the governing standards to comply or to follow, in the course of overpayment recoupment and in response to an overpayment refund request in the  managed care market. More dangerously, due to the lack of understanding and guidance from any authorities at the federal and state levels, health-care providers simply ignore such requests from the payers of health-care plans and their recovery agents. The insurance companies, health-care plan payers and managed care TPA's have started to simply withhold or deduct such "overpayment" from subsequent benefit reimbursements, asserting that overpayment is nondisputed and that the provider PPO agreement provision   has authorized the withholding of such nondisputed overpayment.

 

Providers may refuse to refund genuine overpayment, duplicate payment and reimbursement that the claimant is legally ineligible for, arguing that insurance companies have failed to reimburse other legitimate claims for the amount that is more than the overpayment requested from the insurance company.

 

Providers across the nation may also refuse to refund legitimate "overpayment" by arguing that they are the "innocent third parties" even for legitimate "overpayment" and ignoring to challenge, by appealing, the alleged overpayment that may have been incorrectly claimed by the plan as it might be retrospective claim denial but overpayment, which may foreclose any appeal rights the claimant or provider may have to these "denial-overpayment-no-appeal-then-overpayment" claims.

 

More and more frequently, TPA's or plans simply claim any retrospective claim denials as overpayments and demand from providers for unconditional refund or make recoupment from future claim payment deductions without affording appeal process as provided by applicable federal or state laws. One tragedy in this recoupment practice is the failure of recognition of benefits overpayment dispute as being always conducted as provider contract dispute as to appeal process.

 

Or even worse, this kind of dispute is moving into national fraud or anti-fraud initiative to gain advantage over cost savings movement.

 

 

"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."

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."

 

In this regard, the entire nation has failed to see the dangerous impact of this new managed-care Holy War and unanticipated backslash to both sides of health care crisis. To providers, withholding true overpayment from payers has just started a war of recoupment from payers by deductions from your future payments and PPO Audits or fraud investigation, and once deduction recoupment is in operation, providers are guaranteed in losing end as payers are paying party with controls. To Plans or payers, unreasonable and tricky overpayment or recoupment will set off a national uncontrollable medical claim inflation by providers to "charge back" by increasing billing and charging to get even, "Discretionary Price Gauging"  or "Discretionary Medical Inflation", then every one in the healthcare system will be recouped: "GM says health care obligation hit $67.5 billion in 2003" (AP Wire, 03/11/2004)

ERISA is the governing Law for 80% of health-care claims in this country. ERISA specifically prescribes steps to be taken by every party to resolve overpayment disputes. The appeal process in accordance with ERISA claim regulation will help and protect every one involved in this type of overpayment recoupment practice and overpayment refund request.

 

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)

 

Contrary to the popular understanding and healthcare expert's assertion that "There is no statutory appeals process for a physician to question a health plan’s decision that he or she owes the plan a refund." (www.texmed.org), ERISA  statutorily prescribes the regulatory appeal process "for a physician to question a health plan’s decision that he or she owes the plan a refund".

 

United States Supreme Court unanimously ordered on May 27, 2003 in BLACK & DECKER DISABILITY PLAN v. NORD that DOL FAQ (Benefit Claims Procedure Regulation), available on DOL web site, is the view of the Supreme Court and must be followed:

 

"It is the Secretary of Labor’s view that ERISA is best served by “preserv[ing] the greatest flexibility possible for . . . operating claims processing systems consistent with the prudent administration of a plan.” Department of Labor, Employee Benefits Security Administration, http://www.dol.gov/ebsa/faqs/faq_claims_proc_reg.html, Question B–4 (as visited May 6, 2003) (available in Clerk of Court’s case file). Deference is due that view." (Bold and underline added) Black & Decker Disability Plan v. Nord , U.S. Supreme Court, Decided 05/27/2003

 

 

 

 

 

I. ERISA Statutory Definition of Claim Denials

 

Under ERISA § 2560.503-1(m)(4), any benefits reimbursement less than 100% of the medical bills must be treated by the plan’s decision as an adverse benefit determination, a partial denial, and it triggers proper notification and appeal process and final decisionmaking by the plan administrator.

 

§ 2560.503-1(m)(4) “The term “adverse benefit determination” means any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a participant’s or beneficiary’s eligibility to participate in a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate.” (underline added).

 

            Department of Labor (DOL) issued specific compliance guidance with this provision through DOL FAQ in C12:

 

“C-12: If a claimant submits medical bills to a plan for reimbursement or payment, and the plan, applying the plan’s limits on co-payment, deductibles, etc., pays less than 100% of the medical bills, must the plan treat its decision as an adverse benefit determination?

 

Under the regulation, an adverse benefit determination generally includes any denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit. In any instance where the plan pays less than the total amount of expenses submitted with regard to a claim, while the plan is paying out the benefits to which the claimant is entitled under its terms, the claimant is nonetheless receiving less than full reimbursement of the submitted expenses. Therefore, in order to permit the claimant to challenge the plan’s calculation of how much it is required to pay, the decision is treated as an adverse benefit determination under the regulation. Providing the claimant with the required notification of adverse benefit determination will give the claimant the information necessary to understand why the plan has not paid the unpaid portion of the expenses and to decide whether to challenge the denial, e.g., the failure to pay in full. This approach permits claimants to  challenge whether, for example, the plan applied the wrong co-payment requirement or deductible amount. The fact that the plan believes that a claimant’s appeal will prove to be without merit does not mean that the claimant is not entitled to the procedural protections of the rule. This approach to informing claimants of their benefit entitlements with respect to specific claims, further, is consistent with current practice, in which Explanation of Benefits forms routinely describe both payable and non-payable portions of claim-related expenses. See § 2560.503-1(m)(4).” (Underline added)

 

 

II.  Any Benefits Denials Trigger ERISA Compliant Notification of Adverse Benefits  Determination / Explanation of Benefits (EOB)

 

      ERISA § 2560.503-1(g) requires the plan administrator to provide proper notification for any adverse benefits determination in whole or in part, specifically applies to this type of retrospective adverse benefits determination:

 

“(g) Manner and content of notification of benefit determination.  (1) Except as provided in paragraph (g)(2) of this section, the plan administrator shall provide a claimant with written or electronic notification of any adverse benefit determination. Any electronic notification shall comply with the standards imposed by 29 CFR 2520.104b-1©(1)(i), (iii), and (iv). The notification shall set forth, in a manner calculated to be understood by the claimant—

(i) The specific reason or reasons for the adverse determination;

(ii) Reference to the specific plan provisions on which the determination is based;

(iii) A description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary;

(iv) A description of the plan’s review procedures and the time limits applicable to such procedures, including a statement of the claimant’s right to bring a civil action under section 502(a) of the Act following an adverse benefit determination on review;

(v) In the case of an adverse benefit determination by a group health plan or a plan providing disability benefits,

(A) If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination, either the specific rule, guideline, protocol, or other similar criterion; or a statement that such a rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination and that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge to the claimant upon request; or

(B) If the adverse benefit determination is based on a medical necessity or experimental treatment or  similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the plan to the claimant’s medical circumstances, or a statement that such explanation will be provided free of charge upon request.

(vi) In the case of an adverse benefit determination by a group health plan concerning a claim involving urgent care, a description of the expedited review process applicable to such claims.

(2) In the case of an adverse benefit determination by a group health plan concerning a claim involving urgent care, the information described in paragraph (g)(1) of this section may be provided to the claimant orally within the time frame prescribed in paragraph (f)(2)(i) of this section, provided that a written or electronic notification in accordance with paragraph (g)(1) of this section is furnished to the claimant not later than 3 days after the oral notification.”

 

 

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%

(ERISA Failure + Managed-Care) Destroyed US Healthcare
(ERISA Failure + Managed-Care + HSA) Invite US Federal Budget Deficit & Social Security Disasters = 100X 9/11 Attacks

 

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

 

 

III.  Any Benefits Denials Trigger ERISA Appeal Right That Allows And Guarantees the Claimant and Physician To Have At Least 180 Days to Appeal to the Plan Administrator/Claim Fiduciary On "Overpayment" Denials And Refund Request

 

ERISA § 2560.503-1(h) requires the plan administrator, instead of any unauthorized revenue recovery specialists, to establish reasonable claim procedure, completely listed in the plan's SPD, to designate an appropriate named fiduciary of the plan to provide a full and fair review of the claim of any adverse benefits determination, in whole or in part, for retrospective partial benefits denial, and a claimant shall have at least 180 days to appeal the adverse benefits partial denial, instead of any time frame set forth by any unauthorized recovery entities:

 

“(h) Appeal of adverse benefit determinations. (1) In general. Every employee benefit plan shall establish and maintain a procedure by which a claimant shall have a reasonable opportunity to appeal an adverse benefit determination to an appropriate named fiduciary of the plan, and under which there will be a full and fair review of the claim and the adverse benefit determination.

(2)  Full and fair review. Except as provided in paragraphs (h)(3) and (h)(4) of this section, the claims procedures of a plan will not be deemed to provide a claimant with a reasonable opportunity for a full and fair review of a claim and adverse benefit determination unless the claims procedures—

(i)   Provide claimants at least 60 days following receipt of a notification of an adverse benefit determination within which to appeal the determination;

(ii)  Provide claimants the opportunity to submit written comments, documents, records, and other information relating to the claim for benefits;

(iii) Provide that a claimant shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant’s claim for benefits. Whether a document, record, or other information is relevant to a claim for benefits shall be determined by reference to paragraph (m)(8) of this section;

(iv) Provide for a review that takes into account all comments, documents, records, and other information submitted by the claimant relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.

(3)  Group health plans. The claims procedures of a group health plan will not be deemed to provide a claimant with a reasonable opportunity for a full and fair review of a claim and adverse benefit determination unless, in addition to complying with the requirements of paragraphs (h)(2)(ii) through (iv) of this section, the claims procedures—

(i)   Provide claimants at least 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determination;

(ii)  Provide for a review that does not afford deference to the initial adverse benefit determination and that is conducted by an appropriate named fiduciary of the plan who is neither the individual who made the adverse benefit determination that is the subject of the appeal, nor the subordinate of such individual;

(iii) Provide that, in deciding an appeal of any adverse benefit determination that is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate, the appropriate named fiduciary shall consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment;

(iv) Provide for the identification of medical or vocational experts whose advice was obtained on behalf of the plan in connection with a claimant’s adverse benefit determination, without regard to whether the advice was relied upon in making the benefit determination;

(v)  Provide that the health care professional engaged for purposes of a consultation under paragraph (h)(3)(iii) of this section shall be an individual who is neither an individual who was consulted in connection with the adverse benefit determination that is the subject of the appeal, nor the subordinate of any such individual; and

(vi) Provide, in the case of a claim involving urgent care, for an expedited review process pursuant to which—

(A) A request for an expedited appeal of an adverse benefit determination may be submitted orally or in writing by the claimant; and

(B) All necessary information, including the plan’s benefit determination on review, shall be transmitted between the plan and the claimant by telephone, facsimile, or other available similarly expeditious method.

(4)  Plans providing disability benefits. The claims procedures of a plan providing disability benefits will not, with respect to claims for such benefits, be deemed to provide a claimant with a reasonable opportunity for a full and fair review of a claim and adverse benefit determination unless the claims procedures comply with the requirements of paragraphs (h)(2)(ii) through (iv) and (h)(3)(i) through (v) of this section.”

 

Page 3 of 10, Group Enrollment and Coverage Agreement - Part A, January 1, 2005(r)


"Return of Overpayments

"Under BlueCard, recoveries from a Host Plan or from participating providers of a Host Plan can arise in several ways, including but not limited to, anti-fraud and abuse audits, provider/hospital audits, credit balance audits, utilization review refunds, and unsolicited refunds. In some cases, the Host Plan will engage third parties to assist in discovery or collection of recovery amounts. The fees of such a third party are netted against the recovery. Recovery amounts, net of fees, if any, will be applied in accordance with applicable BlueCard Policies, which generally require correction on a claim-by-claim or prospective basis."

 

BCBSIL; Update on Auto-Recoupment Process

 

"Refund Request Process

When we identify an overpayment, a refund request letter is sent to the payee which explains the reason for the refund and includes a remittance form and return address envelope. If the contracting provider fails to return the overpayment, BCBSIL reserves the right to deduct any such payment from any other payment due the provider from BCBSIL."

 

 

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.

 

 

IV.  Any Benefits Denials Trigger ERISA Guaranteed Full and Fair Review (Appeal) with Complete Disclosure of Fee Schedules

 

§ 2560.503-1(m)(8) defines “relevant document” as the following:

 

“(8) A document, record, or other information shall be considered “relevant” to a claimant’s claim if such document, record, or other information

(i)   Was relied upon in making the benefit determination;

(ii)  Was submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination;

(iii) Demonstrates compliance with the administrative processes and safeguards required pursuant to paragraph (b)(5) of this section in making the benefit determination; or

(iv) In the case of a group health plan or a plan providing disability benefits, constitutes a statement of policy or guidance with respect to the plan concerning the denied treatment option or benefit for the claimant’s diagnosis, without regard to whether such advice or statement was relied upon in making the benefit determination.”

 

Department Of Labor (DOL) interprets § 2560.503-1(m)(8), "relevant document" to mean and include:

 

“B-5: For purposes of furnishing relevant documents to a claimant, what kind of disclosure is required to demonstrate compliance with the administrative processes and safeguards required to ensure and verify appropriately consistent decision making in making the benefit determination?

 

What documents will be required to be disclosed will depend on the particular processes and safeguards that a plan has established and maintains to ensure and verify appropriately consistent decision making. See 65 FR at 70252. The department does not anticipate new documents being developed solely to comply with this disclosure requirement. Rather, the department anticipates that claimants who request this disclosure will be provided with what the plan actually used, in the case of the specific claim denial, to satisfy this requirement. The plan could, for example, provide the specific plan rules or guidelines governing the application of specific protocols, criteria, rate tables, fee schedules, etc. to claims like the claim at issue, or the specific checklist or cross-checking document that served to affirm that the plan rules or guidelines were appropriately applied to the claimant’s claim. Plans are not required to disclose other claimants’ individual records or information specific to the resolution of other claims in order to comply with this requirement. See § 2560.503-1(m)(8)(iii).  See question D-12.” (underline added)

 

V.  ERISA Requires Consistent Decisionmaking in Initial Benefits Determination with Paid Claims and Subsequent Audits of Paid Claims, That Is Only Based on the Governing Plan Documents

 

In order to show that the  claim procedure and benefits determination, in initial benefits determination with reimbursement and subsequent "overpayment" determination in the recent audits campaign of previously paid claims, have been consistently made in accordance with the governing plan document of the particular ERISA plan instead of irrelevant and nonrelated commercial recovery guidelines, § 2560.503-1(b)(5) requires that only the governing plan documents be used and relied upon in making benefits determination and similarly situated claims shall be consistently considered in the initial and subsequent "overpayment" calculations.

 

2560.503-1(b)(5) “The claims procedures contain administrative processes and safeguards designed to ensure and to verify that benefit claim determinations are made in accordance with governing plan documents and that, where appropriate, the plan provisions have been applied consistently with respect to similarly situated claimants.”

 

Department Of Labor (DOL) interprets § 2560.503-1(b)(5), "consistent decision making and safeguards", to mean and include:

 

“B-4: What kind of administrative processes and safeguards must a plan have in place to ensure and verify appropriately consistent decision making?

 

The department did not intend to prescribe any particular process or safeguard to ensure and verify consistent decision making by plans. To the contrary, the department intended to preserve the greatest flexibility possible for designing and operating claims processing systems consistent with the prudent administration of a plan. The department believes that prudent plan administration requires ensuring that similarly situated claims are, under similar circumstances, decided in a consistent manner. Consistency in the benefit claims determinations might be ensured by applying protocols, guidelines, criteria, rate tables, fee schedules, etc. Consistent decision making might be ensured and verified by periodic examinations, reviews, or audits of benefit claims to determine whether the appropriate protocols, guidelines, criteria, rate tables, fee schedules, etc. were applied in the claims determination process. See § 2560.503-1(b)(5).” (bold & underline added)

 

VI.  Differentiate Overpayment Refund Request from Provider Discount v. Benefits Dispute

 

Patient Disputes Provider Disputes, (DOL FAQ A8); Provider/MCO Contract (PPO/HMO) Disputes are not Triggered until Patient ERISA Disputes With the ERISA Plan Are 100% Resolved or Moot (DOL FAQ C12) (PASCACK VALLEY HOSPITAL, INC. v  LOCAL 464A UFCW WELFARE REIMBURSEMENT PLAN (3rd Cir. 11/01/2004)

 

DOL, FAQ, A8 clarifies HMO or PPO Discount v. ERISA Claim Denial:  the Provider's HMO or PPO contractual dispute will have no effect on a claimant’s ERISA right to ERISA benefits under an ERISA plan and the Provider's HMO or PPO contractual dispute is not triggered or has no effect on the medical claim UNTIL a claimant’s ERISA right to ERISA benefits under an ERISA plan is resolved or moot.
 

 

"A-8: Do the requirements applicable to group health plans apply to contractual disputes between health care providers (e.g., physicians, hospitals) and insurers or managed care organizations (e.g., HMOs)?

 

No, provided that the contractual dispute will have no effect on a claimant’s right to benefits under a plan. The regulation applies only to claims for benefits. See questions A-3, A-4, A-5.  The regulation does not apply to requests by health care providers for payments due them -- rather than due the claimant -- in accordance with contractual arrangements between the provider and an insurer or managed care organization, where the provider has no recourse against the claimant for amounts, in whole or in part, not paid by the insurer or managed care organization.

 

The following example illustrates this principle. Under the terms of a group health plan, participants are required to pay only a $10 co-payment for each office visit to a preferred provider doctor listed by a managed care organization that contracts with such doctors. Under the preferred provider agreement between the doctors and the managed care organization, the doctor has no recourse against a claimant for amounts in excess of the co-payment. Any request by the doctor to the managed care organization for payment or reimbursement for services rendered to a participant is a request made under the contract with the managed care organization, not the group health plan; accordingly, the doctor’s request is not a claim for benefits governed by the regulation.

 

On the other hand, where a claimant may request payments for medical services from a plan, but the medical provider will continue to have recourse against the claimant for amounts unpaid by the plan, the request, whether made by the claimant or by the medical provider (e.g., in the case of an assignment of benefits by the claimant) would constitute a claim for benefits by the claimant. For information on authorized representatives of claimants.  See questions B-1, B-2, B-3.

 

 

VII.  Make Timely Refund for "Overpayment", "payment in excess of what is due" under the Plan, Such As, Including but Not Limited to Duplicate Payments, Payment for More Than 100% Claimed, Payment for Claimant with False Identity, Payments Due To Pure Clerical Errors.

 

ERISA plans, governmantel plans will sought from providers who receive the incorrect payment that claimant is NOT legally entitle to.

 

Popular innocent party argument by providers may not help.

 

These are some examples:

Claims Adjustments and Recoupments

OPM Part Two,Chapter 5

"1. Provider Overpayments

 

Overpayment refunds shall be sought from the provider who received the incorrect payment in the following situations:"

 

c. Overpayments Resulting from Alleged Misinformation

 

"An allegation by a patient or provider that information obtained from a health benefits advisor, contractor, or other party caused the overpayment does not alter the liability for the overpayment, or is it grounds for termination of recoupment activity."

 

 

OVERPAYMENTS RECOVERY - AT-RISK FUNDS

CHAPTER 11, SECTION 3

 

"2.1. Provider Overpayments

 

Overpayment refunds shall be sought from the provider who received the incorrect payment in the following situations:"

 

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."

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

 

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

 

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."

 

 

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

 

 

VIII.  ERISA Timeline within Which an "Overpayment Request" Can Be Made.

 

ERISA does not provide a regulatory statute of limitations for benefit claims, retrospective benefits denial and recoupment or for a lawsuit that can be filed, courts usually will apply appropriate state's statute of limitation period if the plan SPD and documents do not have a clear provision for timely filing claims and time limit for litigation. In a fully-insured plan (with a commercial insurance policy), an insurance policy usually has a provision as a contractually imposed statute of limitations with in which a lawsuit can be filed. Since most overpayment recoupment request are virtually retrospective benefits denial, an ERISA plan's contractual statute of limitation for litigation would be most applicable for a time limitation if any ultimate legal action can be taken to recoup alleged overpayments. Therefore it is important to appeal immediately to the plan administrator or fiduciary, to obtain a copy of Summary Plan Description (SPD) of the Plan governing the dispute and to determine if the plan has right to recoup from health-care providers. It is important to know that if recoupment request is based on provider contract dispute or ERISA benefits dispute. If the plan SPD has provided a clear provision of statute of limitations, federal courts usually will enforce that provision and disregard any extra contractual statute of limitations, such as a third-party agreement with providers, or even a state's statute of limitations for breach of contract actions. The federal court, instead of state court, will be the choice of jurisdiction for an employee ERISA benefit dispute, state laws will be preempted by ERISA unless overpayment recoupment is based on provider contract discount dispute.

 

IX Overpayment Due to Retrospective Discovery of "Termination of Coverage"

 

A more and more frequent overpayment refund request was due to retrospective review and discovery of termination of contract/coverage of the patient/group/plan due to plan sponsor's failure to contribute and/or forward employee payroll deduction to the TPA or insurer to cause insufficient fund to pay or retrospective cancellation of insurance policy.  In this scenario, Labor Department will be the most appropriate federal agent to enforce this type of noncompliance by the plan.  Other possibilities might be termination of employment due to resignation or firing of employee to cause lack of health plan coverage, the most appropriate appeal process would be under COBRA, Notice of COBRA Practice.  Other scenarios would be pre-existing condition exclusion or waiting period.

 

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

"Columbus, Ohio - The U.S. Department of Labor has sued defunct General Clay Products Corporation, of Columbus, Ohio, for abandoning the company’s retirement plan, and also filed suit against its president for failing to forward employee contributions to the health plan. The alleged violations resulted in the loss of health insurance coverage for company workers."

 

    "Over-payment claims" Due to Retrospective Benefits Denial Must Be Adjudicated As Federal Claims under § 502(a) of ERISA.

 

    In sum, "Over-payment claims" due to retrospective benefits denial are claims dispute for benefits due under the terms of an ERISA plan and recoupment claims seeking to enforce a term of the ERISA plan are within in the scope of § 502(a) and must be adjudicated as federal claims under  § 502(a) of ERISA. Singh v. Prudential Health

"No Recoupment for Insurer That Mistakenly Overpaid Disability Benefits for Four Years" (EBIA  via Google.com)

 

Dandurand v. Unum Life Ins. Co. of America, 2001 U.S. Dist. LEXIS 10723 (D. Me. 2001)

 

AETNA US HEALTHCARE, INC. v.JOHN CLIFFORD MADIGAN, JR.

 

"Recoupment "'is the setting up of a demand arising from the same transaction as the plaintiff's claim or cause of action, strictly for the purpose of abatement or reduction of such claim.'" Newbery Corp. v. Fireman's Fund Ins. Co., 95 F.3d 1392, 1399 (9th Cir. 1996) (quoting 4 Collier on Bankruptcy,"

 

"CONCLUSION

Aetna' s claim for overpayments of LTD benefits that were recoverable under the Policy and the debtor' s right to postpetition benefits for a separate disability claim did not arise from the same transaction and were not logically related. Thus, recoupment was not available to Aetna. The prepetition claim was discharged by the debtor' s intervening bankruptcy, and Aetna violated the discharge injunction by deducting the balance of the overpayments from the debtor' s benefits. Therefore, the bankruptcy court' s judgment awarding relief to the debtor is AFFIRMED."

 

Court Decisions: Recoupment of Past Overpayments (self-fundhealth.com)

 

"... Recoupment of Past Overpayments. Insurer overpaid participant for a five year period. ... Such recoupment is not a remedy under ERISA. ..."

CMS:  Medicare Overpayments - A two sided tri-fold brochure (August 2004) (PDF format 19Mb)

 

"Physician Disagreement with the Overpayment

 

The physician has the right to appeal the decision if he or she disagrees with the overpayment. Effective with Joint Signature Memorandum #255, dated June 3, 2004, recoupment will cease as a result of a demand letter if: (a) the first recoupment action occurred after December 8, 2003, and (b) a first level appeal has been received."

 

"What is an Overpayment?

 

Overpayments are Medicare funds a provider or beneficiary has received in excess of amounts due and payable under the Medicare statute and regulations. Once a determination of overpayment has been made, the amount of the overpayment is a debt owed to the Federal Government.  Federal law requires CMS to seek recovery of overpayments, regardless of how an overpayment is identified or caused......."

 

    Even for Medicare claims, retrospective benefits denial and recouping practice is for claims dispute over the benefits due instead of genuine "over-payment" dispute, and such retrospectively denied claims seeking to recoup from providers to enforce Medicare rules must be adjudicated as federal claims under Medicare Act, established under Title 18 of Social Security Act, 42 U.S.C. §§ 1395-1395gg.

 

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

 

      For those non-ERISA and non-Medicare claims, the legal principle in retrospective claim denial for benefits or coverage v. genuine "over-payment" refund and recoupment is similar although choice of laws and jurisdictions is different.

 

    As "Over-Payment" crisis becomes more popular for hospitals and providers, failure to appeal over-payment refund and subsequent recouping will cause you financial disasters, a NEW components (recouping = negative "Revenue Cycle") of  "Revenue Cycle" advanced in: 

HFMA Roundtable: Emerging Roles in Revenue Cycle Leadership 

HFMA Executive Roundtable: Best Practices in Revenue Cycle System Implementation

 

 

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.”

Maximum Comfort, Inc v. Tommy G. Thompson

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

 

 

 

 

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)."

 

*************************************************************

*************************************************************

 

 

 

For more specific information, practical Appeal Letters and Response to Overpayment Refund Requests, please contact us or check out our appeal systems and monthly seminars.

 

© 2003  Jin Zhou,  ERISAclaim.com

 

Dr. Jin Zhou is available for special presentations and consulting to any interesting parties on the subject of "Overpayment Crisis" & ERISA Solutions and U.S. health-care crisis turnaround.

 


He can be reached at (630)-736-2974 by phone or by email at  ERISAclaim@aol.com

 


Overpayment Recoupment Crisis for 2004

No Appeal = Denial = No Payments

No Appeals + Deductions >>= Overpayment Recoupment

= "Money Back Guaranteed"

 

950,000 MD's Settled With
Aetna & Cigna on ERISA

 

 

&&&

 

 


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."

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

 

 CONCLUSION

For the foregoing reasons, the court hereby ORDERS as

follows:

1. Plaintiff's motion for summary judgment and permanent injunction is GRANTED;
2. Defendant, and his agents, officers, employees, representatives, and all persons acting in concert or participating with him, are ENJOINED from recouping, offsetting or otherwise collecting from plaintiff any alleged overpayments for any of the beneficiaries which are the subject of this action from any amounts due and owing to plaintiff; and
......

IT IS SO ORDERED.

DATED: June 28, 2004."

 

U.S. FILES COMPLAINT AGAINST NATIONAL ACCOUNTING FIRM UNDER FALSE CLAIMS ACT

 

Press Release   Complaint (pdf)

"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."

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."

"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."

 

Hospital group examines plan for free care

 

"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."

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

 

 

 

New Federal Claim Regulation (Final Rule)

 

After a one year delay, New Federal Benefit Claims Procedure Regulation has become effective January 01, 2003 for almost all of the private group health plans. It will affect about 80% of health-care claims or 60% of health expenditures, approximately 6 million private health and welfare plans and approximately 150 million workers and their dependents  in the U. S..

 

"The regulation will affect participants and beneficiaries of employee benefit plans, employers who sponsor employee benefit plans, plan fiduciaries, and others who assist in the provision of plan benefits, such as third-party benefits administrators and health service providers or health maintenance organizations that provide benefits to participants and beneficiaries of employee benefit plans."

 

The Regulation is the most significant change in health-care laws since 1977, and it has been considered by congressional leaders to be more powerful than proposed Patients Bill Of Rights. "The regulation establishes new standards for the processing of claims under group health plans and plans providing disability benefits and further clarifies existing standards for all other employee benefit plans. The new standards are intended to ensure more timely benefit determinations, to improve access to information on which a benefit determination is made, and to assure that participants  and beneficiaries will be afforded a full and fair review of denied claims."

 

Contrary to the popular belief, the new federal claim regulation provides more protections for physicians and patients than state insurance and Prompt Pay Laws, and more protections and clarifications for insurance companies and the ERISA plan sponsors as well as the third party benefits administrators than state laws in punitive damages as proposed in Patients Bill Of Rights.

 

However, failure to understand and comply timely with the regulation  will invite and suffer from unanticipated financial and legal consequences.

 

AMA has finally noticed the existence and effective date of this new fede

ral 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 and TPA's, 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.

 

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.

 

   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.

 

 

Brief Summary Of the New Regulation

for Physicians and ERISA Plans/TPAs

Effective Date: January 01, 2003

 

For Physicians and Health-care Providers

For Insurance Companies
ERISA Plans/TPAs

ERISA's Prompt Pay Law, better than State Prompt Pay Laws  [29 CFR § 2560.503-1 (f)(i), Page 70267-9] ERISA's Prompt Pay Law, better than State Prompt Pay Laws [29 CFR § 2560.503-1 (f)(i), Page 70267-9]
   
New Assignment of Benefit Form Required for Appeals and Claim Dispute (DOL FAQ, B2-B3) No New Legal Assignment of Benefit Form, No Obligations to Physicians and Health-care Service Providers (DOL FAQ B2), otherwise Obligations to Disclose to Both Patients and Providers (DOL FAQ B-3)
   
No written appeal, no rights, except for claims involved with urgent care. [Page 70255 & 70271] In claims involved with urgent care, physicians/health-care providers are to be considered by default as authorized representatives. [Page 70255 & 70271]
   
The regulation clarifies for the first time since 1977 and prohibits anti-assignment provisions in ERISA plans & (footnote 36). [page 70255 ] [29 CFR § 2560.503-1 (b) (4) Page 70266] Assignments by patients must be absolutely clear as to what extent and capacity, verifications are permitted & (footnote 36). (DOL FAQ B-3) [page 70255 & 70266] [29 CFR § 2560.503-1 (b) (4), Page 70266]
   
Must complete required two levels of appeals, with legal assignment of benefits and specific written request for disclosure of specific plan documents. [Page 70253] No legal assignment of benefits, no response required; no specific written request, no disclosure obligated, however failure to establish and comply with claim procedures, administrative remedies are considered to be exhausted. Lawsuit may follow. [Page 70271]
   
New protections for pre-service claims and urgent care claims against improper pre-authorization, pre-certification and utilization review as well as urgent cares. [Page 70248 & 70271] Understanding of differences in pre-service, urgent care and post-service claims will save big money in fiduciary breach liability claims and POSSIBLE medical malpractice claims[Page 70248 & 70271]
   
New definitions of relevant documents and disclosure obligations, no more medical necessity secrets, UCR fee schedule confidential [Page 70252]  [29 CFR § 2560.503-1 (h)(2)(iii) (m) (4), Page 70268, 70271] [DOL FAQ B-5] No legal assignment of benefits, no obligation to disclose to an assignee, assignment verification by the plan is allowed and protected. Update SPD and any guidelines, only use disclosable and qualified medical claim reviewers. [Page 70252]  [29 CFR § 2560.503-1 (h)(2)(iii) (m) (4), Page 70268, 70271] [DOL FAQ B-5]
   
A Full and Fair Review with new definitions and protection requires de novo reviews on two appeals by at least four different people, two different fiduciaries with ERISA plan, and two different Health-care professionals independent to the ERISA plan. [29 CFR § 2560.503-1 (h) (3)(ii)(iii)(iv)(v), Page 70268-9, (m) (8), Page 70271] [Page 70252-70253] Update SPDs with New Standards and compliance, specify and designate only qualified fiduciaries for appeals, establish new complaint appeal procedures, use only disclosable and licensed as well as certified health-care professionals for medical reviews, pre-certification and prior authorizations in every case. [29 CFR § 2560.503-1 (h) (3)(ii)(iii)(iv)(v), Page 70268-9, (m) (8), Page 70271] [Page 70252-70253]
   
New clarifications on state law preemptions and "independent" medical reviews. No preemption for state laws unless prevention of the application of the new regulation [Page 70254] Comply with both the regulation and state laws in claims involving mixed treatment and eligibility determinations and pure medical treatment decision-makings. [Page 70254]
   
New clarifications with new definitions claim denial/an adverse benefit determination  (payment<100% claimed) or Overpayment, and new protections. (DOL FAQ C-12) Overpayment vs. an adverse benefit determination, recoupment vs. appeal procedures. (DOL FAQ C-12)
   
SPDs must describe...... No SPDs, No decision making
   
Insurance company's decision-making power and disclosure obligations must be described in SPD [29 CFR 2520.102-3 (q), Page 70242] Fully-insured plans with a health insurance issuer being wholly or partially responsible for administering the plan (e.g. payment of claims) must describe insurer's role in SPD. [29 CFR 2520.102-3 (q), Page 70242]
   
Claim fiduciary, whoever makes denial appeal decisions, has duties to disclose SPD and relevant document [29 CFR § 2560.503-1 (h)(2)(iii), (3)(iii) Page 70268-9, (m) (8), Page 70271] or may face up to $110 a day penalty under "Prudent Actions by Plan Fiduciaries" and "Enforce Your Rights."  [29 CFR § 2520.102-3, Page 70243]  Claim fiduciaries or plan fiduciaries have new duties to disclose, without charge, SPD and relevant document [29 CFR § 2560.503-1 (h)(2)(iii), (3)(iii) Page 70268-9, (m) (8), Page 70271] when claim for benefits is denied or delayed, or may face up to $110 a day penalty under "Prudent Actions by Plan Fiduciaries" and "Enforce Your Rights." [29 CFR § 2520.102-3, Page 70243] 
   
More.... More....

 

And many more new and important provisions and protections for health-care providers and insurance companies/ERISA plans/TPA's, as well as patients and employers.

 

Surprisingly and ironically, under current national health-care crisis for everyone, most of us, healthcare providers, payers and administrators, patients and employers, are not ready for this new federal claim regulation, its meaningful and practical compliance and enforcement may save all of us from worsening of national health-care crisis.
 
Don't wait for another 28 years, it's not too late to take actions to become in compliance for your own benefits and protections.
 
 
Our seminars are for everyone, physicians, health-care providers, clinics, hospitals, insurance companies, ERISA plans, third party claim administrators and plan sponsors as well as state insurance regulators.

 

Only with understanding of the regulation and other partners and alliances in our nation's health-care system, our national health-care system will survive and prosper.

 

The Most Powerful & only Seminar in the U.S.
Focused on Health Care
ERISA Claim Regulation Compliance & Appeals For Everyone!

 

Details on Seminar Page

 

Seminar Schedules in IL, VA, NC, Teleconference

 

Call 630-736-2974    FAX to (630) 736-1439

Only One Payment from Your Denied Claims
May Pay off the Seminar or Book Itself!
Why Not Take Actions to Save 40% of Your Business & Headaches?

 

 

    Due to the recent demand from the ERISA plans and TPA's, we're pleased to announce that we also provide educational and consulting services to the ERISA plans, TPA's and managed care organizations on New Federal Claim/ERISA Regulations and Compliance, however we do not provide any services involving actual claim dispute or legal advice for any legal matter or disputes.

 

Associations for Physicians, Hospitals, Health-care Providers

We are willing to work with any associations with your co-sponsorship and significant discount for tuitions and reference books. You may e-mail or telephone for more details.

 

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

 

(ERISA Failure + Managed-Care) Destroyed US Healthcare
(ERISA Failure + Managed-Care + HSA) Invite US Federal Budget Deficit & Social Security Disasters = 100X 9/11 Attacks

 

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 hope, faith and the Law & 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.

DOL 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

Index to ERISA

ERISA topics by Act Section

 

Download Title 29, Chapter 18, of the United States Code ("Employee Retirement Income Security Act" or "ERISA") - From the U.S. House of Representatives downloadable U.S. Code.

 

 

 

TDI

 

 

  
Currently, insurance companies are going back as far as five years to recoup alleged overpayments to physicians
 

“They’ll say, ‘We overpaid you back then,’ which makes it a nightmare for doctor’s offices, having to go back and research and find those bills.  It takes a lot of staff time, plus it’s just bad business practice to come back five years later,” stated Committee Chairman Jesse Woodall, MD

 

 

 

HB 1862 contained a prohibition against health plans coming back to physicians after 180 days and recouping money the plan represents that it had accidentally overpaid to the physician. Physicians currently receive overpayment requests on claims paid up to three and four years before, even though the plan had all the information available to make the overpayment request in a more timely manner. There is no statutory appeals process for a physician to question a health plan’s decision that he or she owes the plan a refund. Although TDI kept a 180-day time limit for the completion of audits, it negated the rule’s effect by allowing the plans unlimited time after the completion of this “indefinite” audit to come back and recoup funds.

 

 

Report of the ERISA Advisory Council's Working Group on Fiduciary Education and Training (U.S. Department of Labor, Employee Benefits Security Administration)

Excerpt: "We strongly urge anyone interested in the issue of fiduciary education to read through the transcripts of our work group's hearings ..."

 

HIPPA Final

 

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.

 

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)

 

Aetna ERISA Settlemnt with 950,000 MD's

 

 

Managed Care and Patients' Rights
(JAMA Editorial)

 

$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"

 

 

Independent Medical Review Experiences in California (California HealthCare Foundation)

 

 

Health Care Issues Stymie Congress (The Hartford Courant)

 

 

 

DOL

 

 

 

 

Kinder and Gentler: Physicians and Managed Care, 1997-2001 (Center for Studying Health System Change)

 

 

 

 

 

 

Employer Spending on Health Care: 1987-2000 (Employee Benefit Research Institute)

 

Office for Civil Rights - HIPAA

OCR Guidance Explaining Significant Aspects of the Privacy Rule- December 4, 2002

 

 

Health Care Spending Rose 8.7% in 2001, the Fastest Rate in 10 Years, Government Statistics Say

 

In Largest Increase in 12 Years, Health Care Spending Rose 7% in 2000 ...

 (KaiserNetwork.org)

 

 

Employer Health Benefits: 2002 Annual Survey.(pdf)
Accessibility verified January 30, 2003
(KaiserNetwork.org)

 

 

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)

 

 

GAO Report: Improvements to Retirement Income Data Needed (U.S. General Accounting Office)

"What GAO Recommends:

The Congress should consider directing Labor to obtain from plan administrators electronic filings of SPDs and summaries of material

modifications and make them publicly available."

 

 

 

 

 

 

Tricare Resources

Icon
TRICARE Handbook


Icon
TRICARE Manuals

 

Claims Adjustments and Recoupments

OPM Part Two

Chapter 5

"1. Provider Overpayments

Overpayment refunds shall be sought from the provider who received the incorrect payment in the following situations:"

 

OVERPAYMENTS RECOVERY - AT-RISK FUNDS

CHAPTER 11

SECTION 3

"2.1. Provider Overpayments

Overpayment refunds shall be sought from the provider who received the incorrect

payment in the following situations:"

 

 

CMS Request for Waiver of Overpayment Recovery

 

MEDICARE PART A

INTERMEDIARY

 

 

BCBSIL Adopts New Overpayment Recovery Program
Blue Review Sept.  2004 (page 5 of 8)

"To address
this issue we are introducing a new recoupment process for refunding overpayments made to contracting providers
for the PPO, BlueChoice and BlueChoice Select products. This procedure will apply to all claim overpayments requested
after October 1, 2004.....

 

If we do not hear from you by telephone or in writing, or you do not return the amount of the overpayment within 30 days from the date of the follow up letter, BCBSIL will recover the overpayment by offsetting current claims payments by the amount due to us."

 

 

REFUND RECOUPMENT LAWS IN ALL 50 STATES (pdf) (www.mtbc.com)

"A healthcare insurer can recover an amount, wrongly paid to a provider. ... the retroactive denial of reimbursement results from COB, ...

 

   
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