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Nov. 18, 2004,Thursday
King of Prussia ~ PA
(Registration Form, PDF)
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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. |
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ERISA Claim
Appeal Book & System Will be Available for Sale at the Seminar
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Dr. Jin Zhou and Dr. Spyros Bakis have agreed to make a
donation to PCA & ANJC for every purchase made. |
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“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 |
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Why ERISA
Seminars for Health-care Providers?
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Pennsylvania Insurance Department's Home Page
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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?
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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.
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Managed Care
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Brief Summary Of
the
New Regulation
for Physicians and
ERISA Plans/TPAs |
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Effective Date: January 01, 2003 |
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For
Physicians and Health-care Providers |
For
Insurance Companies
ERISA Plans/TPAs |
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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] |
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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) |
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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] |
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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] |
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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] |
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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] |
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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] |
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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] |
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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] |
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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) |
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SPDs must
describe...... |
No SPDs, No
decision making |
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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] |
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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] |
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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.” |
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More.... |
More.... |
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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.
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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 |
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Click
here to download Registration Form (pdf) |
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CALL: 570-622-2545, ask for Peggy
MAIL REGISTRATION TO:
ACERTX
Attention: Peggy
1666 Mount Hope
Ave.
Pottsville, PA 17901
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$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 |
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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: |
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·
Independence Blue Cross
·
Highmark BC&BS
·
Capital Blue Cross
·
Aetna and other insurance companies
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·
Horizon BC&BS
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Self insured plans
·
Union Plans, like Teamsters
·
Virtually all health insurance sponsored by an employer |
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Are you ready to learn the new tools available for
Maximum and Prompt Reimbursement
through Compliance?
Then
you need this seminar! |
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What You Will Learn |
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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
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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
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Sponsored by
AcertX, Inc.
CALL: 570-622-2545, ask
for Peggy
Click here to
download Registration Form (pdf) |
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Our
Previous Seminars in Pennsylvania
Presents
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Saturday,
February 1, 2003 ~ 8:30 a.m. - 5:00 p.m. |
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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 |
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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
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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. |
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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.
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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 ERISAclaim 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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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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