"Maximizing Healthcare Claim Reimbursement
- Problem Oriented Appeals under
ERISA"
Did you know that ERISA completely
controls or regulates all of your claim denials and delays from
employer-sponsored plans, as long as your dispute is reimbursement:
"denial of benefits", and if you were very and really frustrated?
(Unanimous US Supreme Court Decision on June 21, 2004) Did you also
know that most employer-sponsored plans in USA, not only
self-funded/insured but also fully-insured (through purchase of
insurance), are ERISA plans, and most of your reimbursement claims
for patients under age of 65 are ERISA claims?
|
Aetna Health Inc. v. Davila
06/21/04
Opinion of the
US Supreme 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. 4–20."
"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),......" |
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What is
the law protecting patients against managed care problems for
claims with employer sponsored health plans?
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Why did a
US Supreme Court unanimously rule on June 21, 2004 that ERISA
governs all of your claim denials or money problems from an
employer sponsored health plan and ERISA supersedes all of your
state laws for your "denial of benefits" (money problems) in your
managed care troubles?
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Federal
ERISA claim regulation protects patients from all of your managed
care troubles, such as claim delays, coverage denials,
"over-payment" money back hassles, choice of network and
providers, prior-authorizations, policy "limit", silent PPO's,
"Mad HMO's", down-coding and bundling to pay only a fraction
of your claims, medical necessity problems, and all of your
managed care problems;
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How to
best use federal ERISA and state laws in utilization review
(UR/medical necessity review) and external reviews to get your
claim paid timely and reasonably?
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ERISA
claims compliance and anti-fraud and abuse prevention.
ERISA, the federal law, requires every
ERISA plan to disclose every relevant information for each denied
claim, and provides most powerful full and fair reviews to protect
patients and providers, but ERISA was never fully understood and
taught to health-care providers and the billing industry nationwide.
New Denial
Crisis Demanding for New Solutions
for Your
Reimbursement Problems
In 2007, healthcare
providers are facing unprecedented reimbursement crisis for healthcare
claim denials, delays and "overpayment" recoupment as well as managed
care PPO audits.
Several years ago, most
health care providers were seeing class actions against insurance
companies and managed care entities by 950,000 physicians across USA
after terribly failed political actions of "Patient's Bill of Rights"
campaign for eight years, and desperately hoping to see some positive
changes. In last several year those class actions were either settled
or dismissed by federal court.
Do you see any major
positive changes for your reimbursement?
No!
Now in 2007, the game is
totally different. More and more healthcare providers are the target
of healthcare fraud lawsuits and investigations, PPO fraud and abuse
audits, and more detrimentally harmful to financial bottom line for
many healthcare providers and facilities. We have been experiencing
more and more Volcano type of PPO audits and tornado type of
overpayment recoupment crisis from payers withholding subsequent claim
payments for millions of dollars, while no federal or state agency
seemed to have jurisdictions for healthcare provider’s Katrina crying
for justice, and while state government declined to intervene because
of ERISA preemption and federal government refused to investigate
because of alleged provider network contract agreement dispute, but
healthcare providers on behalf of your patients received no payments
or little payments for already approved claims as a result of
"overpayment" recoupment by the payers.
Most Comprehensive Research and
Analysis from US Supreme Court Rulings
US supreme court
unanimously ruled on June 21, 2004 that ERISA, a federal law, controls
and governs your problems in managed care crisis if you want any money
from the employer sponsored health plans.
Most Comprehensive, Advanced And
Practical Appeal Letters For “Overpayment Recoupment” Due To PPO
Audits And Medical Necessity As Well As Poor Documentation For Both
Self-Funded ERISA Plan And Fully-Insured ERISA Plan
Our new 2007 major
updates provide you with most powerful protections and advanced appeal
letters based on all of US Supreme Court recent rulings on managed
care reimbursement, ERISA state law and PPO preemption, state law
medical review preemption, and every type of practical arguments used
by payers in withholding and recouping benefits payment from
healthcare providers for those already approved benefits claims.
Latest Federal Court Ruling on
Disallowing Health Plan Recovery or Recoupment against Healthcare
Providers
Two new federal court
rulings on overpayment and state law prompted pay preemption relied
upon most recent US Supreme Court rulings, in addition to our 2006
updates in this area.
Latest Federal Court Ruling on
Definitive ERISA Preemption of State Prompt Pay Law.
For years, federal and
state regulators, legal and health care experts, health care providers
and insurance companies are not certain if federal law ERISA preempts
state Prompt Pay Laws, now federal court has ruled clearly that ERISA
definitely preempts state prompt pay laws based on analysis of Supreme
Court recent rulings.
97.96% Claims of United
Healthcare Lawsuit in These Case Were ERISA Claims
You will be also
surprised to learn that in this provider lawsuit against United
healthcare for wrongful denial of benefits claims
"Plaintiffs
lawsuit centers around 295 claims for services rendered by Schoedinger
to patients covered by United healthcare plans. 289 of these claims
qualify as Employee Welfare Benefit Plans under ERISA, and 6 involve
non-ERISA plans.5 268 of the ERISA claims surround self-funded or
self-insured health plans, in which the employers are financially
liable for any benefits due and United serves only as the plan
administrator and claims processor. 21 of the ERISA claims and all of
the non-ERISA claims involve health plans that are fully insured by
United. For these 27 claims, United is financially responsible for the
benefits due to plan participants and serves as the plan administrator
and claims processor."
No PPO Participation, No Checks
to Non-PPO Providers, but ERISA Laws Protect You
Because certain major payers are no longer sending reimbursement
checks to healthcare providers who were not participating in the
network, we have thoroughly researched federal law, ERISA, and
developed a most powerful but straightforward action plan package
based on specific federal ERISA regulation and requirements for
healthcare providers to receive reimbursement checks directly from the insurance payers.
New Federal Government Guidelines
on Filing Benefits Claims and Appeals
Our 2007 major updates
also include latest federal government, DOL, guidance on filing
healthcare claims and appeals
New Federal Government Guidelines
on Pre-Existing Condition Denials and Protections
Our 2007 major updates
also include latest federal government, DOL, guidance on filing
healthcare claims, appeals for pre-existing condition protections.
Our U.S. employment
market in modern society, divorce, relocation and adoption as well as
newborn babies have caused countless mysterious claim denials and
delays due to mysterious “additional information requesting” by payers
from patients and health care providers, but healthcare providers can
never find out what exactly addition information the payers are
looking for. These confidential information is not about privacy
compliance but pre-existing condition investigation, also governed by
HIPAA, money part of HIPAA regulation.
HIPAA pre-existing
condition regulation was never fully understood by healthcare
providers, as HIPAA is part of ERISA regulation.
If you want to get paid
quickly and accurately for 90% of your non-Medicare claims from
patients obtained health insurance from employment in private sectors,
you must understand and follow published federal government
guidelines.
How to Sign up?
Our new 2007 ERISA
Seminars can be enrolled by
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Calling
630-736-2974
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Download,
fax a completed Registration Form to:
630-736-1439
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Online Secured registration.
