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New Federal Health Claims & Appeals Laws
&
Regulations
for 193 Million Americans
Effective 09-23-2010
©2010, Jin
Zhou, ERISAclaim.com |
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President
Obama Signing Health Bill on
03/23/2010
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President
Gerald R. Ford Signing ERISA on 09/02/1974 |
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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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UNITED STATES
DEPARTMENT OF LABOR
(Links to DOL)
©2010, Jin Zhou, ERISAclaim.com |
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Statutory Laws [PDF]
[PDF]
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Employee Retirement Income Security Act ERISA |
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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)
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California
SB 1569/Knox-Keene Act, "Allowing
Physicians to Sue Health Plans for Fair Payment",
Will be Preempted by ERISA
(Copyright © 2004
by
Jin Zhou,
ERISAclaim.com)
08/30/2004
"The article is to
explore whether the Employee Retirement
Income Security Act of 1974 (ERISA), 88 Stat. 832, 29
U. S. C. §1001 et seq., pre-empts
California
"SB 1569"/Knox-Keene Act
to the
extent it applies to ERISA plans.
I believe
it does, in accordance with the Supreme Court ruling for both
Egelhoff
v. Egelhoff
and
Aetna
Health Inc. v. Davila."
DOL
Advisory Opinion 96-06A
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California
Assembly Passes Bill Allowing Physicians to Sue Health Plans for
Fair Payment (California
Physician)
[Posted 08/26/04]
"Despite
opposition from the health plan lobby, the state Assembly this
week passed a bill that would strengthen a physicians right to
sue a health plan when the plan fails to make fair and timely
payment for care provided to its enrollees. The CMA-sponsored
bill (SB 1569) was defeated earlier this week by one vote, but
was brought up for a second vote due to vigorous lobbying by CMA
staff and physicians."
"Despite
Californias new payor abuse regulations, and the passage in the
past few years of statutes that penalize health plans for unfair
payment practices, the problems persist.
CMA officials said the bill would give physicians a very
effective tool to combat unfair health plan practices."
Click here for the SB 1569 bill summary.
"SUMMARY: Authorizes health care
providers to bring an action against a health plan for
unpaid claims in specified conditions. Specifically,
this bill:
1) Allows physicians that have direct contracts with a
plan to bring a statutory cause of action, akin to an action for
breach of contract, to enforce specified Knox-Keene Act
obligations regarding claims processing and payment,
regardless of whether these Knox Keene provisions are written in
to the contract.
2) Provides for physicians that do not contract directly
with a health plan but do have a contract with an intermediary
of a health plan, a cause of action against the plan for unjust
enrichment if the physician provided services to an
intermediary that has become insolvent and the plan was
negligent in delegating its payment responsibilities to the
intermediary.
3) Provides for emergency care physicians that do not
contract directly with a health plan or an
intermediary of a health plan, a cause of action against the
plan for unjust enrichment if the physician provided
services and submitted a claim to an intermediary that has
become insolvent, regardless of whether the plan was negligent
in delegating its payment responsibilities to the intermediary."
Click here for more on
SB 1569 Senate Bill - Bill Analysis (http://info.sen.ca.gov)
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2. "SB 1569"/Knox-Keene
Act regulates
benefits payment ("related to"), 80% health care claims covered
under ERISA;
3. "SB 1569"/Knox-Keene
Act creates a new
third-party cause of action by changing or creating new
statutory designation of derivative beneficiaries of an ERISA
claim, as prohibited in "Egelhoff
v. Egelhoff " (Supreme
Court, March 21, 2001).
4. "SB 1569"/Knox-Keene
Act creates
impermissible connection to ERISA plans, 80% of the health care
claims, thus preempted by ERISA.
5. "SB 1569"/Knox-Keene
Act will be
completely preempted by ERISA as Supreme Court recently ruled in
"Aetna
Health Inc. v. Davila"
(Supreme Court, June 21, 2004).
Although "SB 1569"/Knox-Keene
Act will be
practically beneficial for non-ERISA claims, it will be preempted by ERISA for most
majority of health care claims under ERISA.
The article is to
explore whether the Employee Retirement
Income Security Act of 1974 (ERISA), 88 Stat. 832, 29
U. S. C. §1001 et seq., pre-empts
California
"SB 1569"/Knox-Keene Act
to the
extent it applies to ERISA plans.
I believe
it does, in accordance with the Supreme Court ruling for both
Egelhoff
v. Egelhoff
and
Aetna
Health Inc. v. Davila.
After settling with Aetna and CIGNA, health care providers
across the country continued to experience claim problems or "the
problems persist", with healthcare plans.
Healthcare providers and state legislators focused on solutions in state
legislation and continued to ignore the facts that ERISA plans cannot be sued in
the state court for benefits payment by private employer-sponsored employee
benefits health plans.
Ultimate responsible party for ERISA plans is ERISA plan
itself and any nonfiduciary delegatees, middleman MCO, and middleman IPA's
cannot be sued by non-ERISA recognized third parties in the state court for
benefits payment from ERISA plans governed under ERISA
in federal courts and
interpreted repeatedly by Supreme Court in managed-care disputes.
Almost all private employer-sponsored health plans are
governed under ERISA, almost 80% of health care claims are ERISA claims.
Misleading and
misdirecting ERISA benefits claims by physicians to the state
court instead of federal court for cause of action under ERISA may
make "the problems persist" worse.
Only practical solution in the
near future for physicians and Healthcare providers is to educate themselves on
ERISA and comply with ERISA claim regulation.
CLEGHORN V BLUE SHIELD OF
CALIFORNIA
9th Cir., 05/23/2005
OPINION
CANBY, Circuit Judge:
"We are presented once again with a question concerning the degree to which
the federal Employee Retirement Income Security Act (ERISA) preempts state
law. Douglas D. Cleghorn is a participant in his employers ERISA health plan
offered by Blue Shield of California (doing business as Care-America) (Blue
Shield). On one occasion he sought and received emergency medical services
and Blue Shield denied reimbursement. Cleghorn sued Blue Shield in
California state court, asserting state-law causes of action and alleging
that Blue Shield had violated an emergency care provision in section
1371.4(c) of the California Health and Safety Code. Blue Shield removed the
case to federal court and the district court held that Cleghorns claims were
preempted by ERISA. When Cleghorn declined to amend his complaint to allege
an ERISA claim, the district court dismissed his complaint for failure to
state a claim. We affirm the judgment of the district court."
Comment from ERISAclaim.com:
In a lawsuit for
reimbursement of emergency medical services fees for emergency room visit ,
plaintiff's California state court claim based on layperson
standard, alleging that Blue of California violated
an emergency care provision in section 1371.4(c) of
the California Health and Safety Code, and plaintiff's refusal to
follow ERISA rules when given a chance in federal court, is preempted by
ERISA and therefore completely dismissed.
In simplest English-language, if anyone is disputing or
claiming any money payment, even one penny from an ERISA sponsored health
plan, regardless its managed-care shape, HMO or PPO, or its severity,
emergency or nonemergency, ERISA law controls your dispute and lawsuit, your
state laws are completely preempted by ERISA.
If your claim is from health insurance through employment
in private sector, it is an ERISA claim.
ERISA claim regulation provides for
better protections for patients and physicians.
Once again, failure by providers and
patients to follow ERISA claim regulation and to take legal action under
ERISA will result in more damages to our entire healthcare system, by continuing to rely upon state laws to
argue an ERISA claim and case.
DOL
Advisory Opinion 96-06A
"This is in response to your request for an advisory opinion concerning the
applicability of Title I of the Employee Retirement Income Security Act of 1974
(ERISA). Specifically, you ask whether California's Knox-Keene Health Care
Service Plan Act of 1975, California Health & Safety Code Section 1340 et seq.
(Knox-Keene), would be preempted by section 514(a) of
Title I of ERISA if it were applied to prohibit a welfare benefit plan
from providing participants with incentives to influence their choices among
alternative benefits offered under the plan."
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. 420."
"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
fur-ther proceedings consistent with this opinion.7
It is so ordered."
Egelhoff v. Egelhoff
EGELHOFF
v. EGELHOFF, a minor, by and through her natural
parent, BREINER, et al.
"certiorari to the supreme court of
washington
No. 99-1529. Argued November 8,
2000--Decided March 21, 2001
While David A. Egelhoff was married to
petitioner, he designated her as the beneficiary of a life
insurance policy and pension plan provided by his employer
and governed by the Employee Retirement Income Security Act
of 1974 (ERISA). Shortly after petitioner and Mr. Egelhoff
divorced, Mr. Egelhoff died intestate. Respondents, Mr.
Egelhoff's children by a previous marriage, filed separate
suits against petitioner in state court to recover the
insurance proceeds and pension plan benefits. They relied on
a Washington statute that provides that the designation of a
spouse as the beneficiary of a nonprobate asset--defined to
include a life insurance policy or employee benefit plan--is
revoked automatically upon divorce. Respondents argued that
in the absence of a qualified named beneficiary, the
proceeds would pass to them as Mr. Egelhoff's statutory
heirs under state law. The trial courts concluded that both
the insurance policy and the pension plan should be
administered in accordance with ERISA, and granted
petitioner summary judgment in both cases. The Washington
Court of Appeals consolidated the cases and reversed,
concluding that the statute was not pre-empted by ERISA. The
State Supreme Court affirmed, holding that the statute,
although applicable to employee benefit plans, does not "refe[r]
to" or have a "connection with" an ERISA plan that would
compel pre-emption under that statute."
"Justice Thomas delivered the
opinion of the Court.
A Washington statute provides that
the designation of a spouse as the beneficiary of a
nonprobate asset is revoked automatically upon divorce.
We are asked to decide whether the Employee Retirement
Income Security Act of 1974 (ERISA), 88 Stat. 832, 29
U. S. C. §1001 et seq., pre-empts that statute to
the extent it applies to ERISA plans. We hold that it does."
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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
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950,000 MD's Settled
With Aetna & Cigna on ERISA
Rx-1
$$$$$$$$$ERISA $$$$$$$$$$
Rx-2
US
Supreme
Court Visits ERISAclaim.com
at 11:57:03 AM on Friday, November 21,
2003
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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. |
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ERISA Laws/Rules
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ERISA in US CODE
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HIPPA Final
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$10,600 ERISA Claim
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| 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.
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$37,350 ERISA Claim
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| 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.
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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." |
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ctnow.com
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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" |
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