|
|
|
Nov. 18, 2004,Thursday
King of Prussia ~ PA
(Registration Form, PDF)
|
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)."
Complaint and Grievance Appeal
Information:
 |
Click on the PDF Links below for information
on how to resolve problems with your managed care plan.
|
|
|
Managed Care
|
|
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 |
| |
|
|
