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Moukawsher & Walsh, LLC
Pension and Employee Benefit Law

Benefitlawyers.com

 
 

SPD's for FEHB

Federal Employees Health Benefit Plan

Federal Employees Health Benefits Program
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FEHB Plan Brochures

Links to Plan Brochures for 2003

Links to Plan Brochures for 2004

Federal Employees Health Benefits Program

FEHB HANDBOOK

 
 
 
 
 
 

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at 11:57:03 AM on Friday, November 21, 2003
Seminar Schedules in ILNC, PA, VA, OH,  Teleconference

 

 

 

Click The State Name for Time, Location & Agenda of Each Seminar

Seminar Schedules in IL NC, PA, VA, OH, SD, Teleconference

Nov. 18, 2004,Thursday
King of Prussia ~ PA
(Registration Form, PDF)

ERISAclaim.com

 

The Pennsylvania Chiropractic Association, in conjunction with the Association of New Jersey Chiropractors and ERISAclaim.com, will present a comprehensive Insurance and Managed Care Seminar for all Chiropractors and their staff.

ERISA

The Super Power To

Chiropractic Collections 

Thursday, November 18, 2004

Radisson Hotel Valley Forge ~ Buchanan Room ~ King of Prussia ~ PA

 Dr. Jin Zhou and Dr. Spyros Bakis

Reimbursement & Compliance Consultants

www.ERISAclaim.com

 You will learn how to properly handle all denials such as:

Ø     Medical Necessity or Maintenance Care

Ø     Bundling & Down Coding Denials

Ø     Policy Exclusion Denials, No DC Coverage

Ø     Overpayment Refund Requests & Already Paid Claims Auditing

Ø     Denials of Physical Therapy Treatment Administered by a Chiropractor

Ø    Multiple Co-Payments on the Same Visit

You will also learn how to properly request the Summary Plan Description (the policy), relevant plan documents, rate tables, medical review reports and more.

You will learn what the Federal rules for health insurance claims are and how they are primarily protecting you.

 

ERISA: The Super Power To Chiropractic Collections

Thursday, November 18, 2004

Radisson Hotel Valley Forge ~ Buchanan Room
 King of Prussia ~ PA

(Registration Form, PDF) 

Doctor’s Name: _____________________________________________________________________
                    PCA Member  _____                                      ANJC Member _____         
Address: ____________________________________________________________________________
City: __________________________________________   State: __________  Zip: _______________
Phone: __________________________________           Fax: _________________________________
List of Attendees:
1._____________________            2.________________________           3. _____________________
Registration – Lunch On Your Own

_____  Total Number of Attendees                                    $249.00 for each attendee
 

$199.00 per attendee if you register by October 18, 2004.

All registrations MUST be received 8 days prior to program date.  No late or at-door registrations will be accepted!!!
 

Register By:    FAX:  717.232.8368      MAIL:  PCA, 1335 North Front Street, Harrisburg, PA 17102

______Check Enclosed(Please make checks payable to: PCA) Amount Enclosed $__________

Credit Cards: ______ Visa     ______ MasterCard   ______ American Express     ______ Discover

Card Number:   ________________________________________ Expiration Date: ______/______
 

Signature: _____________________________________  Amount to be Charged $_____________
 

Registration Policy:

All registrations MUST be faxed or mailed to PCA Headquarters.  No telephone registrations will be accepted.

Cancellation Policy:

All cancellations MUST be in writing.  A $50.00 administrative fee will be withheld per attendee.  “No Shows” the day of the seminar are liable for the entire fee.  Every attempt is made to offer this program as announced.  This program will not be cancelled due to inclement weather except in the event of a State Emergency.  PCA is not responsible for any expenses incurred by registrants due to program adjustments or cancellations.  For further information call the PCA at 717.232.5762 or the ANJC at 732.264.4200.

ERISA Claim Appeal Book & System Will be Available for Sale at the Seminar

Dr. Jin Zhou and Dr. Spyros Bakis have agreed to make a donation to PCA & ANJC for every purchase made.

“ERISA for Physicians:  Healthcare ERISA Claim Denials & Appeals”With 2004 Update
$450.00        CD Book – More than 790 pages and Electronic Version of all of the appeal letters found on CD Book with free technical support for CD Book and free appeal network support for 15 days

Why ERISA Seminars for Health-care Providers?


Pennsylvania Insurance Department's Home Page

 

ACT 68 - Your Rights
What to do if you have a problem with your managed care health insurance plan. Your Rights Under Act 68

"These provisions are for enrollees of managed care plans. The two best known types of managed care plans are health maintenance organizations (HMOs), and "point-of-service" (POS) plans. Act 68 does not apply to preferred provider organizations (PPOs) that do not require use of a primary care physician 'gatekeeper' or to traditional indemnity fee-for-service health insurance plans. If you have a problem with a PPO or health insurer, contact the Insurance Department at 1-877-881-6388 for assistance."

Act 68 - Managed Care Process
Do all managed care plans follow this process?

Do all managed care plans follow this process?

There may be different procedures for handling complaints and grievances if you are:

  • a federal employee or dependent enrolled in a managed care plan
  • a Medicare or Medicaid recipient enrolled in a managed care plan
  • employed by a business that is self-funded or self-insured (ERISA)

Act 68 - Problem Handling
Steps for handling a problem

Act 68 - Urgent Problems
What if my problem is urgent?

 

 
 

What's New

UR Denial Contract Language
 
   (Note:  Published in Pennsylvania Bulletin (01/01/2005) 

"4. If plan medical policies are used as part of the decision making process, the relationship of those policies to contract language must be referenced in the subscriber contract. Reference to plan medical policy as the sole basis for the denial is unacceptable. Medical policies are secondary to contract language and the UR denial letter must include the contractual basis with the medical policy as the secondary basis. If there is no direct linkage to the contract, the use of medical policies cannot be the sole basis for the denial.

An example of an acceptable linkage between policies and contract would be a request for service where a Plan medical policy has been developed that defines “xyz service to be considered cosmetic, and excluded under the terms of the contract, unless certain medical criteria are met.” The reference to such criteria in the medical policy alone as the basis for the denial is not sufficient and there needs to be a clear linkage to the terms of the subscriber contract that excludes cosmetic services.

Denial letters referencing medical policy must identify that medical criteria used for decision-making are available upon request if the denial is based on medical criteria. "

Communicating the UR Decision

 
   (Note:  Published in Pennsylvania Bulletin (01/01/2005) 

Health: Certified Review Entity (CRE) Application

"Any entity intending to perform utilization review on behalf of managed care plans and/or to conduct external grievance appeal reviews must be certified as a utilization review entity by the Department of Health, in accordance with the provisions of Act 68 Managed Care regulations (40 P.S. §9912101, et seq.) and the Department of Health's managed care regulations (28 Pa. Code, Chapter 9, Subchapters K and I)."

CRE Application
 

 

Prov Dispute
 
 

Complaint and Grievance Appeal Information:

 2002 PA MCO Member Appeals Guide
Click on the PDF Links below for information on how to resolve problems with your managed care plan.

 

 
  QUICK LINKS


Managed Care

  What's New
  Certified Review Entity (CRE) Application
  PPO Instructions and Applications
  Managed Care Reports
  Enrollee & Provider Appeal Information
  Consumer Alerts
  Technical Advisories
  Managed Care Regulations
  HMO Contact List
 
 

 

 

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] 
Failure to timely make benefit determination and review decisions by the plan administrator will constitute "deemed denied" review/appeal and "deemed exhaustion of administrative remedy" under § 2560.503-1(l), ("a decision on the merits of the claim" = de novo judicial review, instead of deferential judicial review) that will forfeit or preclude the plan from "deferential review standard" on judicial review in federal court, the most important part of "ERISA Shield" on ERISA land Gilbertson v Allied Signal Inc

DOL interprets § 2560.503-1(l) through CFR accompanying supplementary information on page 70255: “The Department’s intentions in including this provision in the proposal were to clarify that the procedural minimums of the regulation are essential to procedural fairness and that a decision made in the absence of the mandated procedural protections should not be entitled to any judicial deference.”

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.

 

Past Seminars in PA.

Sponsored by AcertX, Inc.

Sponsored by AcertX, Inc.

Gerald F. Hermann, Esq.

David G. Novatnak, D.C., C.P.C.

 

DATE: October 11, 2003

TIME: 9:00 to 5:00

PRESENTED BY:
ERISAclaim.com
Jin Zhou, D.C.
Spyros Bakas, D.C.

LOCATION:

Sheraton in Langhorne
(Philadelphia area)
400 Oxford Valley Road
Langhorne, PA 19047
Phone: 215-547-4100

Click here to download Registration Form (pdf)

CALL: 570-622-2545, ask for Peggy
MAIL REGISTRATION TO:

ACERTX
Attention: Peggy
1666 Mount Hope Ave.
Pottsville, PA 17901

$175.00 PREREGISTERED
includes up to 2 persons from office
$35.00 each additional
Received Before October 7, 2003

$225.00 AT THE DOOR
includes up to 2 persons from office
$50.00 each additional

Are you losing collections due to the following denials?

Medical Necessity
Bundled services
Part of another service
Integral to another service
The E/M is considered included in the CMT
This service is considered investigational and experimental
 

Name the service
Third Party Payers will find a reason not to pay
for legitimate services!

 Some of the major insurers in your area that may have denied your request for reimbursement are as follows: 

 

·       Independence Blue Cross

·       Highmark BC&BS

·       Capital Blue Cross

·       Aetna and other insurance companies

 

·       Horizon BC&BS

·       Self insured plans

·       Union Plans, like Teamsters

·       Virtually all health insurance sponsored by an employer

Are you ready to learn the new tools available for

Maximum and Prompt Reimbursement
through Compliance?

 Then you need this seminar!

What You Will Learn


Your new rights

Do you know as a provider that you have rights under the new federal law – ERISA?
Do you know these new rights provide for Maximum protection and prompt payment of claim?
Do you know that under the new federal law third party payer must fully disclose the reason for their action?  Simply stating “not medically necessary” is not acceptable.

Why 80% of all Health Care Claims
• are governed by new Federal Law as of January 1, 2003

Why New Federal regulations
• Implement new standards for claim processing
• Ensure more timely payment
• Improve access to information used to deny or bundle your claims
• Guarantee a full and fair review of an appealed claim
• Disallow “kangaroo courts” to make payment and coverage determinations
 

Why your present “Assignment of Benefits” is useless to enforce these new rights.
• You need more than just the right to receive payment

Why general appeals will not work
• Appeals must be specific and compliant with the new regulation
Why there must be a prompt and timely response to appeals
• No more “black holes” to lose claims and appeals

How to obtain a valid assignment and become an “authorized representative”
• No more “have the patient call us”

How to obtain the “Summary Plan Description” (SPD)
• The SPD controls how the plan operates

How to obtain up to a $110.00 a day fine for non-compliance with Federal regulation
• $110 a day, day after day, until the health plan complies

 

Sponsored by AcertX, Inc.

CALL: 570-622-2545, ask for Peggy

Click here to download Registration Form (pdf)

 

Our Previous Seminars in Pennsylvania

Presents

Stop Managed Care Abusive Claim Delays & Denials!
Getting Paid by Compliance with New Federal Claim (ERISA) Rules

The Most Powerful & only Seminar in the U.S.
on Health Care
ERISA Claim Denials & Appeals

A $1.0 Trillion Nuclear Solution to Our Nation's Health-care Crisis &
$44 Trillion Future U.S. Budget Deficit

 

Saturday, February 1, 2003 ~ 8:30 a.m. - 5:00 p.m.

 

Are You Ready for
the New Federal Claim Regulations?

The Pennsylvania Chiropractic Association presents Dr. Jin Zhou & Dr. Spyros Bakis

speaking on ERISA Claims

Saturday, February 1, 2003 ~ 8:30 a.m. - 5:00 p.m.

After a one year delay, the New Federal Benefit Claims Procedure Regulation will become effective in 2003 for almost all of the private group health plans. It will affect about 80% of healthcare claims or 60% of health expenditures. The new standards are intended to ensure 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 popular belief, the regulation provides more protection for physicians and patients than state laws and the Patients’ Bill of Rights. The regulation also provides the best protection for Doctors of Chiropractic.

v    New assignment of Benefit Form required for appeals and claim dispute

v    No written appeal, no rights, except claims involved with urgent care

v    The regulations clarify for the first time since 1977 and prohibits anti-assignment provisions in ERISA plans

v    New protections for pre-service claims and urgent care claims against improper pre-authorization, pre-certification and utilization review

v    New definitions of relevant documents and disclosure obligations, no more medical necessity secrets, UCR fee schedule confidentials

v    A full and fair review with new definitions and protection requires de novo reviews on two appeals by at least four different people, two fiduciaries with ERISA plan and two different healthcare professionals independent to the ERISA plan

Are you ready for this new federal claim regulation? The meaningful and practical compliance and enforcement of this regulation may save all healthcare professionals further suffering of a national healthcare crisis. For your own benefit and protection, do not wait to take action to become compliant.

Continuing Education Credits are not offered for this course

For additional information on these important federal regulations visit, ERISAclaim.com

Click here to download a fax copy of Registration Form

ERISA    Claims Seminar - Dr. Jin Zhou -

Clarion Hotel & Convention Center - February 1, 2003

1700 Harrisburg Pike
Carlisle, PA 17013

Map & Directions
(717) 243-1717

Name_____________________________________________DC
License#______________Address_______________________________________
City_____________State_______Zip_____Phone_____________Fax____________

Regular Registration:

____PCA Member  ................................$150.00
____Non-Member DC ...........................$200.00
____At-Door Registration Add...............$50.00

Register By:   

FAX:  717-232-8368     MAIL:  PCA, 1335 North Front Street, Harrisburg, PA  17102

______ Check Enclosed  (Please make checks payable to PCA)

Credit Cards:   _____Visa   _____Mastercard   _____American Express   _____Discover
Card Number__________ Expiration Date: _____/_____ Amount Charged $ _________
Signature:______________________________________________________________

Click here to download a fax copy of Registration Form

 

Registration Policy:  All registrations must be mailed or faxed to PCA Headquarters. No telephone registrations will be accepted.

All registrations must be received by 12:00 noon, Thursday, January 30, 2003 to avoid paying the $50.00 at-door registration fee.

Cancellation Policy:  All cancellations MUST be in writing.  A $50.00 administrative fee will be withheld.   “No Shows” the day of the seminar are liable for the entire fee.  Every attempt is made to offer this program as announced.  PCA is not responsible for any expenses incurred by registrants due to program adjustments or cancellations.  For further information call 717-232-5762.

 

 

Why ERISA Seminars for Health-care Providers?

 
 

 

Seminar Schedules in IL NC, PA, VA, OH, SD, Teleconference

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.

$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 ERISAclaim 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.

 


 

 


 

 


 

Peer Review


 

Groom Law Group


 

 

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.

 

 

 

 

 

Seminar Schedules in IL NC, PA, VA, OH, SD, Teleconference

 
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