Breaking News
950,000 MD's Settled With Aetna & Cigna on ERISA
Prompt Pay Crisis in U.S.
Healthcare Delivery System Demands ERISA Practical Solutions
ERISA Provides Preemptive and "Pre-Prompt Pay"
Protections,
Better Than State Law and Most Powerful Timely Payment
Protections
© 2003 Jin Zhou, ERISAclaim.com
Prompt payment crisis in health-care reimbursement has been identified
as and remained to be
the No. 2 problem by AMA through nationwide
medical Association surveys even after
47 states having enacted "Prompt
Pay" laws and regulations, some very
aggressive state enforcements with
multimillion dollar penalties against late pay insurers and managed-care
organizations, 950,000 physicians nationwide class-action lawsuits in
federal courts, abortion of unprecedented seven-year Patient's Bill Of
Rights legislation campaign in Congress, and managed-care contracting
reengineering between health-care providers and managed-care
organization (MCO) as well as
class-action settlement with Aetna
and CIGNA
in federal court.
Managed-Care
Prompt Pay Crisis? What Does
an Unanimous
US
Supreme Court Say?
On June 21, 2004, an unanimous US Supreme
Court ruled that claim processing (Prompt Pay, timely benefits
determination) and denials of benefits under the
employer-sponsored health plans,
ERISA-regulated benefit
plans,
for
both self-insured and
fully-insured (through purchase of insurance) health plans,
are completely governed by federal law ERISA, that supersedes and
invalidates state laws.
ERISAclaim.com: "employer-sponsored group health plans"
=
"ERISA-regulated benefit
plans",
both self-insured and
fully-insured (through purchase of insurance) health plans,
(ERISA - Title 29, Chapter 18.
Sec.
1002.)
|
Top Seven Issues through
National Medical Specialty Societies |
|
Rank |
Problems Reported By
Popularity Rank |
% |
|
1 |
Bundling |
67% |
|
2 |
Medical Necessity Decision
Denials |
43% |
|
3 |
Prompt Payment |
43% |
|
4 |
Administrative Hassles |
33% |
|
5 |
Coding Issues |
24% |
|
6 |
Downcoding |
19% |
|
7 |
Bargaining Lack of
Negotiation Power |
14% |
|
Top Eight Most Importantly & Frequently Listed
Issues through
State Medical Associations |
|
Rank |
Problems Reported By
Importance Rank |
|
1 |
Downcoding & Bundling |
|
2 |
Prompt Payment |
|
3 |
Lack of Budgeting Power |
|
4 |
Medical Necessity Denials |
|
5 |
Prior Authorization of
Med. Services |
|
6 |
Health Plan Credentialing |
|
7 |
Drug Formularies |
|
8 |
Other |
If NASA Columbia tragedy can find some solutions
for preventions and resolutions, why can't health-care crisis with
potential of paralyzing nation's economy and security deserve and demand
some results oriented and compliant but practical solution?
The
Columbia Accident Report and conclusions identifies the foam debris as the
likely cause and concludes NASA management culture is
the biggest safety
risk, this author, Jin Zhou, identified the ignorance, noncompliance and
nonenforcement
of ERISA claim regulation is the main cause and
American business leaders
hands-free leadership on
employee benefits
management as well as health-care industry and managed-care culture are
the biggest health-care crisis, because ERISA governs and regulates up
to 80% of health-care claims or 60% of health expenditures in the U. S..
ERISA preempts state laws and managed-care contract
enforcement on employee benefits claim delays and denials.
