Last updated 03/06/2004

FREE 2003 Update: (MS Word/Doc) Available for Download

Update in Compliance with New SPD and Claim Procedure Rules

Bundling & Down Coding/PPO Discount under New ERISA Claim Regulation and Supreme Court Unanimous Ruling

Compliant with New ERISA Claim Regulation and HIPAA Rules, Important Update,

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 ERISA 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”.

Medicare CD-Book - $250

(April-May Special Discount $50)

Click Here to Download a Sample with Complete Table of Contents in Bookmark (pdf 1,095kb)

1.       How to establish medical necessity through correct coding and documentation for expanded coverage under New Medicare guidelines, national and local policies;

2.       How to document medical necessity in accordance with Medicare Evaluation and Management Documentation Guidelines from CMS and WPS official publications;

3.       How to prove medical necessity by appropriately ordering diagnostic tests, such as MRI, or CT scans, in accordance with local Medicare LCD to support medical necessity beyond manual palpation and x-rays;

4.       How to obtain, understand and implement CMS “1997 Documentation Guidelines for Evaluation and Management Services”;

5.       How to obtain, understand and benefit from WPS publication: “Evaluation and Management Guidebook”;

6.       How to understand CMS/Medicare initiatives in “Fighting Fraud & Abuse” by enjoying expanded coverage through medically appropriate medical care and documentation without “analysis and paralysis” avoidance of Medicare new chiropractic demo practice;

7.       How to truly understand National Correct Coding Initiative (NCCI) to avoid fraud and abuse with official CMS publications in presentation and reference guide;

8.       How to understand WPS Medicare Part B - Illinois Policy on “Magnetic Resonance Imaging”;

9.       Most importantly, learn how to obtain through Internet, understand and educate yourself for all of these through official publications from CMS and WPS;

Frequently Asked Questions

1.     Who Will Benefit from This Web Site and Services?

2.     Why is ERISAclaim.com So Different?

3.     How to Effectively Use This Website?

4.     Legal Disclaimer

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

1.     Who Will Benefit from This Web Site and Services?

            This Website, consulting and seminar as well as new ERISA CD book are primarily written for physicians, clinics and hospitals or any health-care providers who deal with health-care claims under ERISA, for patients who obtained health insurance through employment in private sectors, up to 80% of U.S. health-care market.  For 27 years, ERISA has been poorly understood by health-care provider community and their patients.  Our nation has spent 1.3 trillion dollars in health-care expenses last year, about 14% of entire national domestic product, two of the four main causes (extremely high administrative costs and managed care problems) are directly associated with healh-care coverage dispute and claims denials under ERISA.

            Managed care market and health-care industry are facing most difficulties and frustrations, many of health-care professionals and medical facilities have changed their business dramatically due to such managed care challenge.  This entire problem is directly related to ERISA statutory structure and administrative enforcement, yet health-care professionals never understand ERISA, let alone any compliance to ensure their ERISA rights. Health-care related litigation explosion is the news media everyday.

            This Website, consulting and seminar as well as new ERISA CD book are mainly focused on ERISA claim denials and appeals, especially at such critical time when new federal final claim regulations are to be effective in January 2002 while health-care providers were hardly informed of this greatest protections for their business survivals.

            This Website, consulting and seminar as well as new ERISA CD book are primarily published and written  for physicians, clinics and hospitals as well as any health-care providers, not preliminary for academic and legal community.  This Website does not focus on basic codings and billings, Medicare, workers compensation, automobile related injuries as well as non-ERISA claims, traditional insurance claims.

2.     Why is ERISAclaim.com So Different?

            While almost 80 percent of health-care claims are ERISA claims, regulated by ERISA for 27 years and our managed care problems escalated each year to almost a breaking point for physicians nationwide, ERISA remains a judicial mystery and courtroom drama.  Nobody has been able to demystify ERISA and make ERISA and everyday health-care claim denials and appeals in one practical package for busy physicians in their day-to-day business practices.  The author of this book has spent about seven years in researching, studying and implementing ERISA principles and applications, including ERISA statutes, regulations, applicable court rulings and real-life claim processing, in everyday ERISA claim appeals practice, and has finally demystified extremely complicated and frustrated ERISA laws, developed a nation first ERISA compliance and appeals system, most comprehensive and practical handbook with numerous computerized sample appeals letters, covering almost every type of commonly seen ERISA denials and appeals, consistent with ERISA statutes and regulations as well as U.S. Supreme Court rulings.  The purpose of this book is to demystify the existing federal laws, promote ERISA compliance by physicians, to file ERISA required and qualified appeals in order to enjoy maximal protections for physician's health-care claims.

3.     How to Effectively Use This Website and New CD Book?

            It is important to understand that this Website and related seminars and consulting services are about compliance, then protections and benefits.  Any principles and strategies referenced on this web site or used in the new CD book are based on existing and sounding legal principles, supported by statutes, regulations and case laws.  It is advised that no expectation of overnight success or miracle shall be promised but great effort of new thinking, persistent studying and unprecedented action taking shall be made by physicians and their businesses.

            The new CD book is written in digital format on a CD, navigation system and tools are more sophisticated than paper format, however reading lengthy information on a computer screen is not popular or practical for most people.  It is suggested that printing selective pages combined with digital navigation and researching tools will maximize benefits of this new book.

            Text files of sample appeal letters for WordPerfect, Microsoft Word and general text word processor are enclosed in this book on the same CD.  Some minimal modification or revision of basic information of these sample appeal letters will make this book one of the most time-saving and effective appeals practice for everyday busy physician's ERISA claim denials.

            Due to its unprecedented nature of knowledge and system, many questions are expected from readers nationwide.  It is not a guarantee of this author to provide individual answers for any possible questions about this book, questions posted through e-mail or posted on this discussion forum of this web site may be answered as an option from this author.

            It is also necessary for future seminars with face-to-face discussion of ERISA claim denial and appeals.  Any health-care professional organizations and medical societies with interest of further promotion of ERISA compliance and understanding of new Federal Final Claim Regulations may contact this author through e-mail or telephone for specific seminars.

            ERISA litigation and court ruling are evolving constantly.  New federal final claim regulations are scheduled to be effective in January 2002.  Physicians and health-care providers are better protected in their medical claim practice by following up with these judicial and regulatory development.  A Registration Form is enclosed with this book for readers in order to provide updated analysis of new court rulings, especially U.S. Supreme Court, and new development of final claim regulations.  It is recommended for readers of this book to complete registration form and be informed of any new development in ERISA court rulings and regulatory updates, traditionally only available to legal community and insurance and benefits industry.

4. Legal Disclaimer

    Except for otherwise specifically stated, our educational and training for certification programs are not affiliated with any governmental or educational institute for the purpose of "recognized accreditation or certification for compliance programs or compliance officers" or degrees. Our certifications are only for personal attendance in private studying subject materials specified in each individual programs for advancing educational knowledge with respect to applicable business and  compliance.

OIG: Special Advisory Bulletin: Practices of Business Consultants [PDF] [http://oig.hhs.gov/fraud/docs/alertsandbulletins/consultants.pdf]
The Office of Inspector General (OIG), Department of Health and Human Services, June, 2001
 

    The First Overhaul for U.S. Health care and GM Is to ERISA-Overhaul GM Health Care Model with Followings:

1. ERISA Compliant SPD with Complete Benefits Coverage, Limits & Exclusions;

2. ERISA Compliant Claims Procedure as the Only Rule for Every One;

3. Elimination of Any Third-Party Managed Care Contracts, UCR & "Medical Necessity"

(GM Current Model: $5.1 billion/yr, $1,400/vehicle)
(GM says health care obligation hit $67.5 billion in 2003)

Health Spending Projections Through 2013

New Federal Claim Regulation (Final Rule)
Benefit Claims Procedure Regulation (FAQ)
Amendments to Summary Plan Description Regulations (Final Rule)
Patient's Rights Claims Procedure Regulation (Fact Sheet)

U.S. Health-care Crisis & ERISA Criminal Enforcement

CBO's analysis of the President's budgetary proposals for fiscal year 2005

Fact Sheet: Affordable Health Care for America's Families (White House)

ERISA Failure Syndrome

U.S. Healthcare Crisis Trilogy

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

?

?

GAO-04-312

?
 

Weirton Steel cancels 10,000

Rx-1  $$$$$$$$$ERISA$$$$$$$$$$  Rx-2

The Root of U. S. Healthcare Crisis

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."

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

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