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Forthcoming Medicare
Seminars |
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Dr. Jin Zhou will be speaking at World
Research Group's
"Summit on Medicare
Advantage Reimbursement for Hospitals"
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E-mail Your Questions to
ERISAclaim@aol.com
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Summit on Medicare
Advantage Reimbursement for Hospitals
Proven Strategies
to Streamline Front and Back-End Processes to Accurately
Identify Patient Benefits and Capture Complete Reimbursement
from Managed Medicare Plans
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Winning Strategies to
Navigate the Medicare Advantage Appeal Process: 2008 Maximum
Reimbursement under Medicare Part C (CMS Web Site-Oriented)
Medicare managed care health
plans, which include Medicare Advantage (MA) plans – such as Health
Maintenance Organizations, Preferred Provider Organizations, Medical
Savings Account plans and Private Fee-For-Service plans – Cost Plans
and Health Care Prepayment Plans, must meet the requirements for
grievance and appeals processing under Subpart M of the Medicare
Advantage regulations. If a Medicare health plan decides to deny,
discontinue or reduce services or payments, in whole or in part, the
plan is required to provide the enrollee, and his/her appointed
representative, with a written notice of its determination and right
to appeal in accordance with “Chapter 13 - Medicare Managed Care
Manual”.
Medicare managed care Part C
reimbursement rules for health care providers are more complicated
than and different from Medicare Part A & B reimbursement rules.
Providers must comply with all of the Medicare claim regulations and
managed providers contracting for maximum reimbursement from MA Plans
under Medicare. Failure by a provider to comply with Medicare
reimbursement and contracting regulations will not only deprive the
provider from substantial reimbursement, but also subject the provider
to overpayment recoupment, fraud and abuse investigation and possible
criminal liabilities.
By attending this
workshop, which will be CMS web site-oriented, you learn how to
navigate or master Medicare Part C 2008 appeal processes and maximize
reimbursements, including:
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How to navigate the Medicare
web site for Part C appeal process
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Medicare Part C
claims-relevant federal statutes, regulations, and Medicare claims
manual
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Definition and Basics of
Medicare Part C, Medicare Advantage (MA) Health Plans (CMS FAQ)
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Medicare Part C appeal
basis, scope, definitions, and types of MA Plans (from Federal
Regulation)
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Medicare Part C appeal
outlines and process – Managed Care appeals flow chart
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MAXIMUS Federal (formerly
MAXIMUS CHDR) – CMS’ Independent Review Entity
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Medicare Part C
appeal-winning strategies – To get paid core without financial
risks, civil and criminal violations
ABOUT YOUR WORKSHOP
LEADER
Dr. Jin Zhou
is a national speaker, consultant, author and publisher of healthcare
Medicare & ERISA claim denials and appeals, regulation education and
compliance. He pioneered, authored and published the nation’s first
ERISA Healthcare Claim Appeal System in a CD book, two Medicare Appeal
Books on CD’s and the nation’s first web site (www.ERISAclaim.com)
in ERISA healthcare claim denials, appeals, claim regulation education
and compliance, in addition, his web site covers extensive information
on new Medicare Appeal regulations for Part A & B, and Part C with
winning strategies for successful appeals.
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Register |
Who Should Attend
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Speakers
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Venue & Pricing
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Conference Overview
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Why Attend |
Agenda |
Back to Conferences |
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Note: Due to high demand, our seminars in 2007 were booked more often by
in-house sponsors and offered on
other locations or
onsite at providers choice and announced by
other sponsors. If you would like
to book a on-site
seminar for your organization, please contact us directly.
Seminars - ERISA, New Federal Laws
for Health-care Claim Denial & Appeals
CALL: 1-630-736-2974
Alert:
We will include one-hour coverage on New Medicare Appeal Process in each of
our ERISA Seminars
Starting from April 2005
Maximal Healthcare Claim Reimbursement
through ERISA Compliance &
Fraud Prevention
Educational Training Programs
For Every One Who Handles ERISA Healthcare Claims
Managed-Care Nightmares?
What Does Unanimous
US Supreme Court Say?
Do You Have Problems with
Health-Care Claims with Employer-Sponsored Health Plans, Claim Denials
and Delays with Providers, and Claim Processing, Denial Management and
Cost Containment with Health Plans?
If yes, we have answers
for all of you: information and guidance from US Supreme Court, Federal
Government on federal laws and regulations to help you and protect you.
Managed-Care Nightmares? What Does
the Unanimous
US
Supreme Court Say?
On June 21, 2004, an unanimous US Supreme
Court ruled that claim processing and denials of benefits under the
employer-sponsored health plans,
ERISA-regulated benefit
plans,
for
both self-insured and
fully-insured (through purchase of insurance) health plans,
are completely governed by federal law ERISA, that supersedes and
invalidates state laws.
ERISAclaim.com: "employer-sponsored group health plans"
=
"ERISA-regulated benefit
plans",
both self-insured and
fully-insured (through purchase of insurance) health plans,
(ERISA - Title 29, Chapter 18.
Sec.
1002.)
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ERISAclaim.com -
Supreme Court Managed Care ERISA Watch
An
Unanimous U.S. Supreme Court Ruling in
Managed Care and Medical Malpractice
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. 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), and thus removable to federal
district court. The judgment of the Court of Appeals is
reversed, and the cases are remanded for further proceedings
consistent with this opinion.7
It is so ordered."
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'External Review' of Medical Claim Denials Is Now the Law
of the Land Nearly Nationwide
(Modern
Healthcare via The Foundation for Taxpayer & Consumer Rights)
Excerpt: "[N]ow that the dust has
settled in the wake of last year's U.S. Supreme Court decision
preventing millions of patients from suing their HMOs for medical
negligence, some legal experts say the practical effects of the
controversial ruling may not be all that substantial-largely because
of the existence of state external-review laws."
What Does ERISA
Mean to Me?
ERISA is a federal law,
Employee Retirement Income Security Act of 1974,
passed by Congress and signed into law,
by President Gerald R. Ford,
on September 2, 1974,
to protect employees and their families, and ERISA
"sets
minimum standards for most voluntarily established pension and health
plans in private industry to provide protection for individuals in these
plans", for
both self-insured and
fully-insured (through purchase of insurance) health plans.
How Can ERISA Protect Me?
Ø
ERISA is a federal law, compliance by every party is mandatory rather
than optional;
Ø
ERISA provides for specific steps, standards and regulations for
employers, insurance companies, health plan, TPA's, and claimants of
patients and health care providers, to administer and claim health care
benefits;
Ø Only
federal law and your compliance can protect you for your rights and
benefits you're legally entitled to under federal law;
Ø If
you know and play by rule of the game, ERISA, you will be protected
and reimbursed maximally under your legal rights.
I've Heard ERISA Is Extremely Complicated Law,
in Past 30 Years No One Has Figured It out How It Works, How Can I Learn
It to Protect Me?
ERISA claim regulation, as it officially published in Federal
Register, is only less than seven (7) pages long [from pages
70265-70271], if you are determined
to learn about it,
you will find out it's not that difficult, besides do
we have any other choice, after everything else has failed in the
health-care system and
"950,000
MD's Settled With Aetna & Cigna on ERISA"?
What Are the Basic
ERISA Regulations or Publications That
I Have To Learn, Because No One, Including Experts and Government, Could
Tell Me Where to Look to Get Started?
These are the basic federal government
ERISA
publications.
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ERISA Seminars for
Healthcare Claim Reimbursement and Denial Management
are slowly,
after 30 years,
but surely
and
finally getting into the mainstream of the
healthcare financial
industry
(pdf, page 2 & page 4), even for
Healthcare Financial Management Association, HFMA, in 2005 for its "32,000
members employed by
hospitals, integrated delivery
systems, long-term and ambulatory care facilities, managed care
organizations, medical group practices, public accounting and consulting
firms, insurance companies, government agencies and other healthcare
organizations." So, you won't be alone or doing something wrong with ERISA. The
question is how you are going to be good or the best at ERISA for denial
management ahead of everyone else in the industry, by finding the best
and taking the best ERISA seminars!
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What Do You Teach about ERISA When No One Has
Talked about ERISA for 30 Years?
You will learn from our
ERISA
demystified
educational seminars, backed with
turn-key
tools and solutions:
1.
The basics of ERISA, definition, how to identify ERISA plans, how
to understand basic terms and definitions of ERISA law and regulations
for health-care claim processing and claim appeals;
2.
How to get paid timely for what
you legally entitled to or process ERISA health care claims with savings
in accordance with ERISA claim regulation, Final Rule, and Summary Plan Description
(SPD) Final Rule, ERISA Frequent Asked Questions from DOL as we outlined
in above "ERISA POWER GUIDES";
3.
ERISA claim regulation or your
state law, which law governs your concerns and disputes, with respect to
coverage, medical necessity and billing & coding, dispute resolution and
appeal process.
Do You Still Remember That Unanimous US
Supreme Court Ruling on June 21, 2004 That ERISA Regulates Completely
"the
Denial of Benefits under ERISA-Regulated Benefit Plans" for
Both Self-Insured and
Fully-Insured Health Plans?
Most, if not all, of your claim processing and claim disputes
are regulated under ERISA, with some of them under your state laws,
including benefits coverage, pre-certification, urgent care, any willing
provider law/network participation, medical necessity,
bundling and down
coding, overpayment refund request, and UCR, PPO discount as well as
whatever problems you are experiencing every day.
Wake up and read
aloud what American Employers and health Plans say after
US Supreme court
unanimous ruling for the most watched managed care lawsuit and how to
get paid for your claims and get the care your patients need: You should
have done your ERISA appeals!!!
American Benefits Council: News Room -
Supreme Court Ruling on Health Care Claims Raises Important Policy
Issues
"Sadly and
predictably trial attorneys and their allies are already calling on
Congress to unravel today’s decision by the Supreme Court,
but they should first ask why the two physicians
in these cases did not act swiftly to help make sure their patients
got the care they were seeking. In neither case did the patient or
their physician seek a further review of the health plan’s initial
coverage decision, despite being specifically informed of their right
to such a review under federal law." Klein said.
"The refusal of the plaintiffs or their doctors
to follow the procedures to either have the plan decision promptly
reviewed, or to go forward with their preferred medical course of
action — taking a different drug (Davila) and staying an extra night
in the hospital (Calad) — even if their eligibility for financial
reimbursement was in doubt — makes the plaintiffs' lawsuits far less
justifiable," Klein noted.
"These review procedures are available under
ERISA to help patients get the care they deserve, quickly and without
having to resort to costly and lengthy legal procedures.
Clearly, a speedy and factual review aided by the expertise of the
physicians involved with these two cases could have avoided the need
for the courts to be involved at all," Klein said.
(The
American Benefits Council is the national trade association for
companies concerned about federal legislation and regulations
affecting all aspects of the employee benefits system.
The Council's members represent the entire
spectrum of the private employee benefits community and either sponsor
directly or administer retirement and health plans covering more than
100 million Americans.)
Aetna
Statement Regarding Unanimous Decision by the U.S. Supreme Court in
Davila V. Aetna
"Aetna is pleased by the Supreme Court’s unanimous
decision announced today, and reaffirmation of the law applicable to
employer-sponsored health plans. For thirty
years the Employee Retirement Income Security Act (ERISA) has helped
employers provide consistent, affordable health benefits to their
employees. It also affords those employees a prompt, fair and
efficient means for quickly resolving coverage disputes. By
affirming the role of ERISA in employee benefits the Court has helped
to assure that millions of working Americans will continue to have
access to quality health coverage provided by their employers."
"Aetna
ERISA Secrets"(www.aetna.com)
Aetna ERISA "Talking
Points" (www.aetna.com)
When Aetna and Cigna settled 900,000
Providers' lawsuit in federal court, they settled on ERISA, but provider arestill
completely clueless on ERISA. Just read US Supreme Court
unanimous ruling for managed denials in the top of this page, then read
how Aetna and Cigna settled with you:
If You Believe Compliance for Claim
Processing and Denial Management As Well As Maximum Reimbursement with
Compliance Are the Principles of Your Business Practice, and Less Than
Seven (7) Pages of ERISA Claim Regulation Is Not Going to Scare You Away
from Achieving Maximum Reimbursement and Plan Costs Containment through
Compliance,
Let's Take Actions to Get Started
on ERISA!
Our ERISA Seminars Are
for Both Sides of Claim Disputes,
Health-Care
Providers and Health Care Plans,
That Is the Beauty Part of Our Program,
Compliance As a Common Ground of Everyone and Every Party, Striving for
Excellency with Integrity.
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For
CFO's,
COOs,
Denial Management
Dept.,
Managed Care Directors,
Contract Managers,
A/R Specialist,
Reimbursement
Manager,
Office Manager, Coder's/Biller's,
Patient Accounting Directors And
Managers,
Risk Managers, Revenue Cycle Directors,
Claims/ Benefit Managers,
"Provider
Sponsored Organization" of HMO's, IPA's &
"Integrated
Health Systems/Networks"
Providers, Payers And Suppliers,
Employer, Insurer,
TPA's,
Appeals Dept., HR,
and More.....
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Disclaimer
Due to the
recent
demand from the
ERISA plans
and TPA's, we're pleased to announce that we also provide
educational and consulting services to
the ERISA plans, TPA's and managed
care organizations on
New
Federal Claim/ERISA Regulations and
Compliance, however we do not provide any services involving actual
claim dispute or legal advice for any legal matter or disputes.
Some have asked why aren't many
infomercial type of student testimonials for ERISA appeal magic and merits.
ERISA appeals are about compliance and then getting paid.
(OIG: Special Advisory Bulletin: Practices of
Business Consultants)
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2005
Schedules
In
IL
Details & Registration
PDF/Fax verion of Registration Form
Online
Registration
Advanced
Certification
Programs |
Jan. 21, 2005, Friday
9 a.m.-5 p.m.
Feb. 18, 2005, Friday
9 a.m.-5 p.m.
Mar. 18, 2005, Friday
9 a.m.-5 p.m. (Changed to SD from IL)
Apr. 15, 2005, Friday
9 a.m.-5 p.m.
May 20, 2005, Friday
9 a.m.-5 p.m.
Jun. 24, 2005, Friday
9 a.m.-5 p.m.
Jul.
22, 2005, Friday
9 a.m.-5 p.m.
Aug. 19, 2005, Friday
9 a.m.-5 p.m.
Sep. 30, 2005, Friday
9 a.m.-5 p.m.
Oct.
21, 2005, Friday
9 a.m.-5 p.m.
Dec.
16, 2005, Friday
9 a.m.-5 p.m.
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Pre-registration |
$225
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(checks for pre-registration must be
postmarked two weeks prior to the seminar) |
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Late registration |
$250 |
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Registration and payment at the
door |
$275 |
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Additional Staff from Same Office |
$150 |
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Previous Attendees |
$150 |
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VIP's |
$0.00 |
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Where |
Vision MRI & CT Of Oak Brook
(In the
Same Building of
Oak
Brook Surgical Center,
Driving Directions)
2425 W. 22nd Street, Suite #205
Oak Brook, Illinois 60523
(click
it for Map & direction)
(Turn South at Tower Drive from W.
22nd St., Under Oak Brook Water Tower)
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For Fax Registration
Click here to Download PDF/Fax verion of Registration Form
For Online Registration or Order
Click here to enter our secured online registration page
Please Specify the Date of Your Seminar on
Registration Form
Tape or any forms of digital recording of seminar are not allowed
Copyright © 2001-2009
Seminar Schedules
in IL,
NC, PA, VA,
OH, Teleconference
We now
offer post-seminar teleconference
for staff training at $190/hour.
Fax To:
(630) 736-1439
A confirmation will be given by fax
CALL: 1-630-736-2974
E-mail Your Questions to
ERISAclaim@aol.com
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2004
& 2003 Past Schedules |
Jan. 23, 2004, Friday
9 a.m.-5 p.m.
Feb 20 ,
2004, Friday
9 a.m.-5 p.m.
Mar 19,
2004, Friday
9 a.m.-5 p.m.
Apr 16 ,
2004, Friday
9 a.m.-5 p.m.
May 14, 2004, Friday
9 a.m.-5 p.m.
Jun 25, 2004, Friday
9 a.m.-5 p.m.
July 16,
2004, Friday
9 a.m.-5 p.m.
Aug
20 ,
2004, Friday
9 a.m.-5 p.m.
Sep.
23, 2004, Thursday
6:00
p.m.-9:00 p.m.
(3Hr CME, Podiatrists Free, $30-$70 Specials,
Download Registration for Details)
Sep.
24, 2004, Friday
9 a.m.-5 p.m.
Oct. 08, 2004, Friday
9 a.m.-5 p.m.
Nov. 12, 2004, Friday
9 a.m.-5 p.m.
Nov. 18, 2004,Thursday
King of Prussia ~ PA
(Registration Form, PDF)
Dec. 17, 2004, Friday
9 a.m.-5 p.m.
Jan.
14, 2003, Tuesday, 9 a.m.-5 p.m.
Feb. 21, 2003, Friday, 9 a.m.-5 p.m.
March 21, 2003, Friday, 9 a.m.-5 p.m.
April 12-13,
Sat-Sun, Canton, Ohio
May 16,
2003, Friday, 9
a.m.-5 p.m.
June 13, 2003,
Friday, 9 a.m.-5 p.m.
July 18,
2003, Friday, 9 a.m.-5 p.m.
Sept. 19,
2003, Friday, 9
a.m.-5 p.m.
Oct. 11, 2003, Saturday, 9 a.m.-5 p.m.
Langhorne, PA
Oct. 17, 2003,
Friday, 9 a.m.-5 p.m.
Nov. 04,
2003, Thursday, 9 a.m.-4 p.m.
Akron, Ohio
Nov. 14,
2003, Friday, 9 a.m.-5 p.m.
Dec. 12,
2003, Friday, 9 a.m.-5 p.m.
April 20, 2002, Saturday, 9 a.m.-5 p.m.
May 17, 2002, Friday, 9 a.m.-5 p.m.
June 21, 2002, Friday, 9 a.m.-5 p.m.
July 26, 2002, Friday, 9 A.m.-5 P.m.
Sept. 27, 2002, Friday, 9 a.m.-5 p.m.
Oct. 25, 2002, Friday, 9 a.m.-5 p.m.
Nov. 22, 2002, Friday, 9 a.m.-5 p.m.
Dec. 13, 2002, Friday, 9 a.m.-5 p.m.
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Our New ERISA
Program Agenda
Seminar Schedules
in IL,
NC, PA, VA,
OH, Teleconference
950,000
Physicians Agreed to Do ERISA Appeals
in
Settlement of Physician
Class-Action Lawsuits
"Aetna
and CIGNA Settlement Secrets"
"Talking
Points"
What You
Should Know about Filing Your Health Benefits Claim
Medicare & ERISA,
Medicare Secondary Payer (CMS)
and
Debts
"Overpayment" Recovery.
ü
Learn the
New Federal (ERISA) Claims Regulations and how they protect and
empower you during claim disputes and WHY
ERISA, a federal law
has been kept
secret for 28 years
Ø
Learn What ERISA is
really about and how it regulates
80% of your health-care claims
Ø
Find out why you need a
new legal assignment of benefits,
Your License for Dispute & Appeals (Q-B2 & B3)
Ø
Find out how to properly
request for
full disclosure on pertinent plan documents (Q-B5, D8, D9, D10 & D11)
Ø
Find out what types of
federal penalties can be imposed on managed care plans that fail to
comply, federal protection against
Bundling & Down Coding,
UCR
&
Medical Necessity Denials
ü
Learn about the
Utilization Review Laws and how they can help fight against
improper, unfair
& noncompliant pre-certification and
medical necessity reviews
ü
Learn all about the NEW
ERISA claim APPEALS PROCESS
Ø
Claim denial is followed
by our ERISA compliant document disclosure request
Ø
Learn how to utilize our
automated appeal templates for specific denial letters
Ø
Learn how to do appeal
letters that focus on
federal laws that preempt state law
Ø
Learn how our
NEW ERISA
claim appeal process places the
burden of proof on the managed care plans, turning table around for
endless paper chase and stressful denial crisis!
Ø
AND more...
Results Nationwide
v
Maximal Reimbursement
through
ERISA Compliance
v
Crisis Turnaround through ERISA Compliance
v
Happy
Staff, Happy Patients
v
Increased Respect from the Insurance Industry and Self-funded ERISA
Plans
v
Devote More Time to Patient Care Instead of Claim Denial Crisis Care
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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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] |
| |
|
|
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. |
Breaking News
950,000 MD's Settled With Aetna & Cigna on ERISA
"Aetna
and CIGNA Settlement Secrets"
"Talking
Points"
What You
Should Know about Filing Your Health Benefits Claim
U.S. Health-care Crisis & ERISA Criminal Enforcement
Are All
Consultants Corrupt? (Fast Company)
Evolving Role of Third Party Administrators Brings
New Demands and
Innovations (Employee Benefit News)
|
|
Happy or Sad 30th Birthday To ERISA?
(Copyright
© 2004
by
Jin Zhou, ERISAclaim.com)
Sept. 2, 2004
On Sept. 2, 1974,
exactly 30 years ago today, ERISA, The Employee Retirement
Income Security Act,
was signed into law by President Gerald R. Ford. The congressional intent in enacting ERISA was to
protect employees in pension and welfare plans, to provide
uniform federal protections in response to the failure of the
Studebaker Co. in December 1963, with thousands of long-service
employees cheated out off their promised pensions, and to
preempt any state laws when the employees pension and welfare
benefits were threatened. 30 years later, ERISA Failure in its
compliance and enforcement left thousands of retirees without
medical benefits, and resulted in a skyrocketing national healthcare expenditure explosion with 45 million uninsured and a possible national pension bailout.
ERISA Failure Syndrome
U.S. Healthcare Crisis
Trilogy
Jin Zhou Identifies "ERISA Failure" That Killed
U.S. Healthcare
"Failure of Imagination"
Again?
|
|
ERISA Celebrates 30th Anniversary As Trouble Brews For the Pension
Insurance Program (Spencer Benefits Reports)
Excerpt: "The seed for
ERISA was planted with the failure of the Studebaker Company in
December 1963, leaving thousands of long-service employees
without their promised pensions."
|
|
Who Can Be a Medical Reviewer under ERISA?
(Copyright © 2004
by
Jin Zhou,
ERISAclaim.com)
U.S.
SUPREME COURT
Docket for 03-83
ORAL ARGUMENT TRANSCRIPTS (page
46 0f 49)
| 02-1845.
Aetna Health Inc. v. Davila |
03/23/04 |
"QUESTION: Mr.
Estrada, you can address what you would like but there are three
points that have come up during the Respondent's presentation
that I'd be interested with a response to.
Number one, is it true
that the people who make the decisions for your client must be
medical doctors in Texas?
MR. ESTRADA:
Well it is true by virtue of DOL regulations which provide that
no claim may be turned down without input from a medical
professional in the relevant area"
|
|
New
Federal Claim Regulation (Final Rule)
-
"Plans must
consult with
appropriate health care
professionals in
deciding appealed claims
involving medical judgment."
[70268-70269,
CFR § 2560.503-1(h)(3)(iii)]
-
"The term `health care professional' means a
physician or other health care professional
licensed, accredited,
or certified to perform specified health
services
consistent with State law." [page
70271
CFR § 2560.503-1(m)(7)]
-
"medical doctors in Texas"
=
MD licensed to practice medicine in Texas
for a Texas ERISA case;
-
"a medical professional in the
relevant area" = relevant area of state laws in license
jurisdiction, scope of practice and relevant local standard of care;
-
"licensed"
= licensed by the State Government/licensing board;
-
"to
perform"
= to practice medicine or health care services in the
State;
-
"specified
health services"
= medical procedures or services being reviewed or denied, instead of
file review or insurance coverage reviews
services;
-
"consistent with State law"
= consistent with State laws where the health care professional is
legally licensed to practice medicine or health care services with
respect to state jurisdictions, scope of license and state local
medical standard of care.
"The term `health care professional' means, in layman term, a
physician or other health care professional who is at least licensed in
your state (and more, board certified too) to practice the
specified/specific health services being reviewed or denied of your
claims, consistent with your state law jurisdiction, scope of practice
and local medical standard of care. Someone who is not licensed to
practice the same health care services specified/denied in your claims
is not qualified as an "appropriate health care
professionals" as defined under ERISA
§ 2560.503-1(m)(7).
Someone who is not licensed in your state to
practice "specified health services" but who is merely registered under
state or other means (URAC, IME, SSD or Peer Reviews) to do Utilization
Reviews (UR)
is not qualified as an "appropriate health care
professionals" as defined under ERISA
§ 2560.503-1(m)(7).
U.S.
Supreme Court visited ERISAclaim.com in regard to ERISA
§ 2560.503-1(h) at 11:57:03 AM on Friday,
November 21, 2003 for this No. one point.
Click here for more coverage of
Supreme Court Visiting at ERISAClaim.com.
|
|
"New
Strike Force" |
Medical Fraud Every Day?
Appeal or Re-Bill After
Denial?
You Must APPEAL
No Re-Billing!!!
Claim Appeal
or
Sentencing Appeal?
Your Choice
Maximal Reimbursement
through ERISA Appeal &
Fraud Prevention
and Compliance
|
|
Aetna:
Leading the Fight Against Health Care Fraud
[PDF]
View as HTML
"Thanks to this highly collaborative
relationship, we know how to identify fraud because we know what
to look for.
Medical Fraud
-
Unusual provider billing practices.
Discrepancy between the submitted diagnosis and the treatment.
Diagnoses or treatments that are outside the practitioner’s
scope of practice.
Claims that are resubmitted
with coding changes to gain benefits.
Alterations on claim
submissions.
Pressure for quick claim payment."
Payments Go Under a Microscope (washingtonpost.com)
January 12, 2004
"MAMSI and CareFirst
recoup overpayments to doctors by making
deductions from future reimbursements.
Doctors can appeal insurers' decisions.
But, in the end, they usually pay up, doctors and insurers
agree."
Employers Audit Workers' Health Claims
(Wall Street Journal via SFGate.com) &
baltimoresun.com - Health plan 'stings' on rise
Excerpt: "Looking to
bring down soaring health-care costs anywhere they can, more
employers are sco>
baltimoresun.com - Health plan 'stings' on rise
Excerpt: "Looking to
bring down soaring health-care costs anywhere they can, more
employers are scouring their health plans for fraud, abuse and
simple mistakes by employees or administrators.
.......The
number of requests for such audits jumped 50 percent last year,
Mr. Farley estimates."
Blue Cross and Blue Shield Association Announces New Strike
Force to Protect American Consumers from Fraud and Fight Rising
Costs (U.S.
Newswire, 4/19/2004)
"DETROIT, April 19 /U.S.
Newswire/ -- The Blue Cross and Blue Shield Association (BCBSA)
today announced a new Anti-Fraud Strike Force comprised of top
Blue Plan investigators that will work with the Federal Bureau
of Investigation (FBI) and other national, state and local law
enforcement agencies to fight major insurance fraud schemes that
rob consumers of millions of dollars annually. BCBSA President
and CEO Scott P. Serota announced the new initiative in a speech
to the Detroit Economic Club."
"The National Health Care Anti-Fraud
Association (NHCAA) estimates that healthcare fraud costs
American consumers more than $50 billion annually. Billing for
services not rendered and misrepresentation of provided services
are the most common types of healthcare fraud."
Clinton Township Firm Convicted of
Overbilling (Macomb
Daily)
"The case is somewhat
unusual in that a corporation was named as a criminal defendant
in the case,
but Kaiser said that is not unheard of since corporate law can
make a firm liable for criminal wrongdoing, and its principal
office holders in return are responsible for any judgments or
punishments the courts impose.
David Griem,
the defense attorney for Emergency Management who was also named
the principal to enter a guilty plea on its behalf,
also could not be reached for comment after the sentencing
hearing. In court, however, he turned over a check to the Blue
Cross insurance company officials in attendance and said the
company would pay the $5,000 court costs on time as well."
Insurers make only small dent in medical-claims fraud
(cbs.marketwatch.com)
"Byron Hollis, national antifraud director for the
association, said the association plans to escalate its
fight against fraud and noted that the group increased
its investigative staff to 500 in 2003, up 30 percent
from fewer than 400 the year before."
"He noted that the association's insurers still might
recover more of last year's fraudulent claim payments
because some of the cases have yet to go to court."
|
|
Denials +
Recoupment =
Inflation +
Fraud or
Cost-Sharing?
Rx =
Compliant Denial & Appeals! |
|
Forbes.com: "Roughly one in seven Americans has
no health insurance. That hurts HCA Inc. (nyse:
HCA -
news
-
people), the largest U.S. hospital chain, which
last year wrote off $2.21 billion
of revenue because patients couldn't pay their
bills."
The American Hospital Association (AHA): "Hospitals today are faced with the challenge of managing their
limited resources, while continuing to deliver the highest standard of care.
According to health care experts, the cost of clinical
denials to individual healthcare organizations averages
$3.3 million
annually. However, many hospitals do not have the resources or the
expertise needed to avoid unpaid days at the end of admissions and lead the
denial-appeals processes."
Payments Go Under a Microscope (washingtonpost.com)
"MAMSI and CareFirst recoup overpayments to doctors by making
deductions from future reimbursements.
Doctors can appeal insurers' decisions.
But, in the end, they usually pay up, doctors and insurers agree."
Hospital Pricing and the Uninsured,
Glenn Melnick, Ph.D.,
"Price
Gouging"
(Subcommittee on Health
Hearing on the Uninsured,
U.S.
FILES COMPLAINT AGAINST NATIONAL ACCOUNTING FIRM UNDER FALSE CLAIMS ACT
(DOJ
Press Release) "January 5, 2004
- PHILADELPHIA –
United States Attorney Patrick L. Meehan announced today the filing of the
Government's
complaint against national accounting firm Ernst & Young.
According to the complaint, nine hospitals paid Ernst & Young for billing
advice – advice which later caused the submission of false claims to the
Medicare program."
Employers Audit Workers' Health Claims (Wall Street
Journal via SFGate.com) &
(MLive.com, MI)
Excerpt: "Looking to bring down soaring
health-care costs anywhere they can, more employers are scouring
their health plans for fraud, abuse and simple mistakes by
employees or administrators.
.......The
number of requests for such audits jumped 50 percent last year,
Mr. Farley estimates."
USATODAY.com - Hospitals Sock Uninsured with Much Bigger Bills
GM to Report $60B in Future Health-Care Obligations
|
What's
???
??? ???
New?
New Federal Claim
Regulation (Final Rule)
Benefit
Claims Procedure Regulation (FAQ)
Amendments to Summary Plan Description Regulations
(Final Rule)
Patient's Rights Claims Procedure Regulation
(Fact Sheet)
What You
Should Know about Filing Your Health Benefits Claim
You
Must Be in Compliance
New Federal
Regulations
Beta Version Of “Patient’s Bill Of Rights”
Have The Answers!
New Federal Claim Regulations
Provide
New Protections after January 01, 2003
¨ New
Assignment of Benefit Form Required for Appeals and Claim Dispute –New
License and Power for Physicians to Appeal Denied or Delayed Claims
(DOL
FAQ, B2-B3)
¨ The
regulation clarifies for the first time since 1977 and prohibits
anti-assignment provisions in ERISA plans --no more “you’re not our
insured”
[CFR 2560.503-1, p 70255 & 70266]
¨ Must
complete required two levels of appeals, with legal assignment of
benefits and specific written request for disclosure of specific plan
documents.
[CFR 2560.503-1, p 70253]
¨ New
protections for pre-service claims (15 days) and urgent care claims (72
hours) against improper pre-authorization, pre-certification and
utilization review as well as urgent cares, better than any
State Prompt
Pay Laws. [CFR 2560.503-1, p 70248 & 70271]
¨ New
definitions of relevant documents and disclosure obligations, no more
medical necessity secrets, UCR fee schedule confidential
[CFR
2560.503-1, p 70252 & 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 peoples, two
different fiduciaries with ERISA plan, and two different Health-care
professionals independent to the ERISA plan. Better protections than any
state insurance laws [CFR 2560.503-1, p 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 [CFR 2560.503-1, p 70254]
¨ New
clarifications with new definitions claim denial/an adverse benefit
determination (payment<100% claimed) or Overpayment, and new
protections. (DOL FAQ, C-12)
More...
Why Are
Your Insurance Denials
Getting Worse Each Year???
Is Managed Care Ruining Your Practice?
Have You Received
Any
Of The Following Denials?
ü
Bundling and Down Coding,
"bundling and downcoding"(AMA),
Patient Not Responsible
ü
Not Medically Necessary
ü
Not Covered due to
Policy Exclusion
ü Your
State Prompt Pay Laws Don't Work for ERISA Plans -
80% of
your
health-care claims
ü
Pre-certification & Prior Authorization Denials
ü
Over the Usual & Customary Charge
ü
Out Of Network Provider Denials
New Seminar in Ohio
New federal law/ERISA Preservice Claims
Pre-certification Denials and Appeals
The
Latest AMA (PSA) Managed Care Hassles Survey through nationwide state
medical associations and national medical specialty societies identified
the most popular and important managed-care claim denials and delays.
|
Top Seven Issues through
National Medical Specialty Societies |
|
Rank |
Problems Reported By
Popularity Rank |
% |
|
1 |
Bundling |
67% |
|
2 |
Medical Necessity Decision
Denials |
43% |
|
3 |
Prompt Payment |
43% |
|
4 |
Administrative Hassles |
33% |
|
5 |
Coding Issues |
24% |
|
6 |
Downcoding |
19% |
|
7 |
Bargaining Lack of
Negotiation Power |
14% |
|
Top Eight Most Importantly & Frequently Listed
Issues through
State Medical Associations |
|
Rank |
Problems Reported By
Importance Rank |
|
1 |
Downcoding & Bundling |
|
2 |
Prompt Payment |
|
3 |
Lack of Budgeting Power |
|
4 |
Medical Necessity Denials |
|
5 |
Prior Authorization of
Med. Services |
|
6 |
Health Plan Credentialing |
|
7 |
Drug Formularies |
|
8 |
Other |
The latest and updated RAND/Harvard Study, funded by the U.S. Department of
Labor (DOL) and requested by Congress, examines the outcomes of nearly a
half-million coverage requests in two large medical groups and revealed
the following:
Traditional Appeals Process
v
Claim Delays & Denials
v
Call Insurance Company &
Spend 40 Minutes
or up to 60% of staff time
v
Generate 1-2 Page Standard Appeal Letter
v
Appeal Letter Focuses On Need Or Benefits Of Care
v
Appeal Letter Focuses On Prompt Pay Laws
v
File Complaint with State Insurance Commissioner
v
Make PAC Contribution to Your State Association
v
If Denial Continues Transfer To Patient Balance
v
If Patient Cannot Pay, Utilize Collection Agency
v
Write off the Entire Balance - Up to 50%
of Your Services!
Results Nationwide
v
Poor-More Than 40% Denials & Getting
Worse Every Day
v
Poor-Increased Overhead, Staff Stress &
Headaches
v
Poor-Bad Patient PR and Loss of Patient
Market Share, Possible Patient Lawsuit
v
Poor-Denial Crisis Survival!
IS YOUR PRACTICE IN A "Health Care
CRITICAL CONDITION"?
Ø
Most
Medical Practices Are Threatened by Reckless Managed Care Claim Denials
Ø
Crisis
Survival and
Endless Paper Chase As Well As Office Staff Stress =
Financial Breaking Point
v
ERISA
is not a type of Insurance, but it is a
Federal Law
v
that
may just save your practice from
reckless denials that are causing our
Nations Health Care System to be in a “Critical Condition”
Forbes.com:
"Roughly one in seven Americans has
no health insurance. That hurts HCA Inc. (nyse:
HCA -
news
-
people), the largest U.S. hospital chain, which
last year wrote off $2.21 billion
of revenue because patients couldn't pay their
bills."
The American Hospital Association (AHA): "Hospitals today are faced with the challenge of managing their
limited resources, while continuing to deliver the highest standard of care.
According to health care experts, the cost of clinical
denials to individual healthcare organizations averages
$3.3 million
annually. However, many hospitals do not have the resources or the
expertise needed to avoid unpaid days at the end of admissions and lead the
denial-appeals processes."
We Deliver the
New Diagnosis and Prescription!
Seminar Schedules
in IL,
NC, PA, VA,
OH, Teleconference
Any
traditional and
conventional appeals without
ERISA
COMPLIANCE are
"squeaky wheel appeals" for any
ERISA claim
denials and delays,
80 percent
of
U.S.
Healthcare claims and
60% of U.S.
Healthcare expenditure.
Coding and billing are
less than
half of the successful reimbursement practice,
coding and billing are not
appealing and coverage dispute practice. Many coders and billers are
wonderful, non-confrontational and very sophisticated individuals, but they
might be terrible and counterproductive debaters, and less than ideal legal
reasoning and logical thinkers. Many financial executives are hands-free
managers in reimbursement divisions.
The
latest Harvard & RAND study for Congress and state legislative debate on Patients'
Bills of Rights, conducted by David Studdert and Carole Roan Gresenz,
study authors from the Harvard School of Public Health and RAND, funded
by federal government, Department Of Labor, and Agency for Health Care
Research and Quality, revealed that
"little is publicly known about such appeals system", and concluded
that "A
majority of preservice appeals disputed choice of
provider or contractual coverage issues, rather than medical necessity.
Medical necessity disputes proliferate not around life-saving treatments
but in areas of societal uncertainty about the legitimate boundaries of
insurance coverage. Greater transparency about the coverage status of
specific services, through more precise
contractual language and consumer education about benefits limitations,
may help to avoid a large proportion of disputes in managed care."
A
JAMA Editorial commenting this study further supported the
conclusion of this study and advanced the
right solutions
more precisely at
New
ERISA Claim Regulations: "Regulations
issued by the Clinton administration in 2000
were designed to infuse rigor into the appeals process maintained by
employer-sponsored health plans covered by the Employee Retirement
Income
Security Act (ERISA),10 which governs insurance arrangements
for more than 150 million workers and their family members. Whether
these rules will be vigorously enforced remains to be seen."
The updated Harvard & RAND study, funded by the U.S. Department of
Labor (DOL), published on June 18, 2003 through Health Affairs, examined the
outcomes of nearly a half-million coverage requests in two large medical
groups that contract with health plans to deliver care and conduct
utilization review, and discovered the
urgency and necessity of expertise of ERISA claim procedure specialists.
The study concludes the following in its summary and policy
implications: "....We found much higher denial rates than those
previously reported.....Denials
made on contractual grounds—the largest share of denials—may call for both
clinical and contractual expertise. Hence, they should ideally be made by personnel who are versant in both areas. There was
some evidence of this sort of dual expertise being brought to bear on
coverage decisions at the two groups we studied."
"......In this environment, contractual coverage and medical-necessity
issues that persist are likely to be for services that enrollees feel
especially strongly about. Such consumer concerns, together with
ongoing consumer protection agendas that include reforms such as guaranteed
external review and right-to-sue provisions, mean that the policy importance
of UR denials in managed care is unlikely to wane in the foreseeable
future."
However these best experts "hired" by Congress and federal government are
one step away from the complete discovery and solution. Let us fill in the
missing links and connect dots in order to save our
health-care system from
collapsing and crisis.
First, we identify the controlling force and power in contractual policy
coverage denial.
The majority of Americans are covered under the
employer-sponsored health-care programs in private sectors under
ERISA,
80%
of the claims and
60% of health expenditures are regulated under
ERISA. Each
individual ERISA plan offers different coverage and benefits,
either
self-insured or fully-insured through purchase of insurance from an
insurance company.
The controlling and governing document for each ERISA
plan is
Summary Plan Description (SPD), the rule of the game for
interpreting each SPD and resolving the disputes on contractual denials is
ERISA claims procedure regulations. Therefore the experts from
Harvard &
Rand study group discovered the importance and necessity of "contractual
expertise" but aborted the solution of "contractual expertise" due to "the
reasons of size or financial stress, this may be beyond the reach of smaller
medical groups that have assumed responsibility for UR".
Financial burden and unavailability of this contractual expertise could be
the final resolution to their study group to determine if those contractual
denials were made by the plan or TPA correctly.
Clinical knowledge and expertise from those medical groups are inherited,
but "contractual expertise" is missing badly for policy coverage,
Summary
Plan Description (SPD) and
ERISA Claims Procedure for 80% of health care
claims, because such
ERISA contractual expertise is nowhere to be found,
even for those very experienced health care attorneys and insurance coverage
experts, as state law governed insurance policy dispute resolution and ERISA
governed claims procedure dispute resolution are quite different, and entire
country has never put ERISA into health-care practice. This is why our
health-care system failed.
If 80% of the health-care claim and 60% of health expenditures are governed
and regulated by ERISA, ERISA plan's "insurance policy" is controlled by
each plan's
Summary Plan Description (SPD), and each claim dispute is
resolved under
ERISA claims procedure regulations, such "contractual
expertise", called for by our Rand/Harvard experts, must be from ERISA claim
procedure specialists.
Therefore, it is absolutely clear that our nation must provide a solution to
health-care crisis by urgently establishing an industry or profession that
will possess not only clinical expertise but also, and more importantly,
ERISA contractual expertise, ERISA claim procedure expertise.
Another 2004 new Rand/Harvard study published on February
2004 issue of
Annals of Emergency Medicine, "Disputes over
coverage of emergency department services: A study of two health maintenance
organizations" discovered that 90% of denial in utilization reviews were
overturned on appeals, from a stratified random sample of approximately
3,500 appeals of coverage denials lodged by privately insured enrollees
between 1998 and 2000 at 2 of the nation's largest HMOs. This study
concludes: "The prevalence of ED cases among all appeals reflects
disagreement between lay and expert judgments about what constitutes
emergency care under the prudent layperson standard. The high rate at which
enrollees win these appeals highlights significant disagreement in
interpretation of the standard among different adjudicators within managed
care organizations (medical groups and health plans). When enrollees fail to
challenge denials that would be reversed on appeal, they bear the financial
brunt of ambiguities in interpretation of the prudent layperson standard."
This new Rand/Harvard study warns that "Although the
end result for consumers is the same in each of these cases, the messages
sent by plans to consumers and medical groups are not. Goodwill payments
imply inappropriate use of the ED (notwithstanding the fact that actual
merit might not have been assessed). Merit-based overturns, on the other
hand, signal an error in utilization review and instruct medical groups
about the proper limits of coverage, instructions that medical groups cannot
ignore because they must meet the cost of these claims. Hence, merit-based
overturns perform a valuable signaling function, akin to the role of
judicial precedent in the law. Unless plans invest additional effort in
educating utilization reviewers about erroneous decisions for which they are
not held financially accountable, goodwill payments of potentially
meritorious cases limit opportunities to forge consensus about the limits of
the prudent layperson standard and to disseminate accumulated knowledge
about its meaning."
"However, some compliance
problems did emerge. Some insurers, Hall told Reuters Health,
initially deny ED claims and then "quickly reverse" their decision
if challenged.
"There are two take-home
messages for health professionals," Hall said. "One, insurers much
less often question the appropriateness of emergency services and
two, if insurers initially deny coverage for emergency care,
providers or patients should appeal."
The impact and enforcement of
prudent layperson laws (Mark A. Hall, JD,
Annals of Emergency Medicine Online,
May 2004 • Volume 43 • Number 5)
[ABSTRACT]
[FULL TEXT]
[
PDF]
Importantly, ERISA claim regulation and definition of
"claim involving urgent care",
29CFR2560.503-1 (m)(1) - Claims Procedure, has
provided governing solutions to "disagreement between lay and expert
judgments about what constitutes emergency care under the prudent layperson
standard." for these privately insured enrollees. And "Unless plans invest
additional effort in educating utilization reviewers about erroneous
decisions for which they are not held financially accountable," and ERISA
claim regulation and definition of "claim involving urgent care'',
goodwill solution will result in
backslash for more disasters
in Emergency Department across the country.
These valuable studies have pointed out the direction but failed to provide
a
turnkey practical solution.
Now that both
Aetna and
CIGNA have
settled the class-action lawsuits by 950,000 physicians and agreed to
process appeals in accordance with ERISA
claim regulations for both ERISA claims and
non-ERISA claims, and to establish external review boards for
Billing and Coding Disputes, Medical Necessity Disputes and
Policy Coverage Disputes, in compliance with state external
review laws, however external reviews will not be available until
internal appeals/ERISA appeals are completely exhausted.
All other 8 major
insurance companies named in class-action lawsuits have refused to
settle,
even if federal court would rule for physicians, the Aetna and CIGNA
settlements will be "as good as it could get" from
the rest of insurers and MCO's as evidenced in Aetna and CIGNA
settlements with physicians.
"Forty
states required individuals to first exhaust their health policy’s
internal appeals and grievance process before seeking external review."
(GAO, September 2003, Page 46) The health policy’s internal
appeals and grievance process =
ERISA
appeals 80% of the time.
Unless physicians understand and complete ERISA internal appeals, all of
those
"a love fest"
and
"victories" from class-action settlements would mean a fantasy of
"a love fest"
to any physicians.
ERISAclaim.com has provided this nation with
a turnkey operational
solution with ERISA compliance,
to educate
everyone on ERISA, coverage and
claim
procedures, to ensure
"Bill Of Rights" for Patients, Providers, Plan
Sponsors and Insurers.
Only appeals with
full ERISA compliance will
ensure
maximum reimbursement or crisis turnaround
at
minimum cost and frustrations.
Nixon Peabody's August 2004 Benefits Briefs: Legal
Developments for Employee Benefits (PDF) (Nixon Peabody
LLP)
6 Pages, Excerpt: "Getting
Burned by Ignoring People with “Colorable” Claims to Plan Participation
You surely know that plan participants and
beneficiaries are entitled to receive copies of relevant plan
documents, if they request them. You also should know that if you
fail to provide requested documents within thirty days a court can
impose a penalty of up to $110 per day for each day you are late.
What if you turn down a request from someone who is not a
participant or beneficiary but thinks he is? You could be in for a
penalty if he has a “colorable” claim.
Lowe v. McGraw-Hill, 361 F.3d 335
(7th Cir. Mar. 15, 2004)."
Aetna
(DOL/ERISA),
First Health,
Blue Cross Blue
Shield are ready to comply with new federal regulation (BCBSIL) (BCBSMI)
(BCBSCNY)
(BCBSNE)
(CareFirstBCBS)
&
(BCBSAL), are
you ready to get paid
faster and fairer?
From
Aetna's ERISA yesterday (Aetna Video Shows ERISA
Patients Mistreated) to
Aetna's ERISA today
(DOL/ERISA) =
Aetna ERISA
Actions or intention in compliance and in
control.
From
AMA's ERISA
yesterday (The latest Harvard & RAND study)
to
AMA's ERISA today (JAMA Editorial)
=ERISA Actions or Not?
That's why physicians, healthcare providers and hospitals
must
wake up on
ERISA now!
AMA
has finally noticed the
existence and effective date of this
new federal
claim regulation, as described in its
January 20, 2003 online edition of American Medical News: "Federal
regulations that dictate rapid turnaround times for health plan claims
and appeals quietly went into effect this month, with little noise from
the managed care industry."
However AMA has failed, as it did in past 28 years,
to practically and
meaningfully understand the
ERISA and its
significance as protections
for health-care providers,
entire industry has failed to offer any
educational programs and
occupational trainings to health-care providers
in this most important
federal law and regulation that governs and
regulates up to
80% of
health-care claims and
60% of U.S. healthcare
expenditures.
As reported by AMA as to the time it may take for
this new federal
claim regulation to take effect in marketplace,
Jeffery Mandell, president of the ERISA Law Group in Boise, Idaho,
states "it often takes years, even decades, for the marketplace to fully
adopt new regulations".
Life is too short, our nation's health-care
system is going through
the worst crisis since World War II and can't
afford another 28 years to
realize and implement the
ERISA regulations.
We, everyone including health-care providers, legislators, regulators
and
insurance companies
and TPA's, should take
immediate actions to educate
everyone in the system and to implement this
new federal claim
regulation as we are fighting against terrorists to save our nation's
health-care system from worse-than-terror-war crisis.
Our seminars are
for everyone,
physicians, health-care providers,
clinics, hospitals,
insurance companies,
ERISA plans, third party claim
administrators and plan sponsors as well as state insurance regulators.
Only with
understanding of the regulation
and other partners and alliances in our nation's health-care system, our national health-care
system will survive and prosper.
Due to the
recent demand from the
ERISA plans
and TPA's, we're pleased to announce that we also provide
educational and consulting services to the
ERISA plans, TPA's and managed
care organizations on
New
Federal Claim/ERISA Regulations and Compliance, however we do not provide any services
involving actual claim dispute or legal advice for any legal matter or
disputes.
Seminar Schedules
in
IL,
NC,
PA,
VA,
OH,
Teleconference
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No
More Managed Care Abuse and Denials!
New Federal Claim Regulations (ERISA)
Effective January
01, 2002
The
Most Powerful and Practical Weapon Against Abuse & Claim Denial
Even
Better than the Patient’s Bill of Rights According to Republican Leader
But
the Insurance Industry & Self-Funded Plans Won’t Tell You!
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The SECRET IS OUT!
Seminar Schedules
in
IL,
NC,
PA,
VA,
OH,
Teleconference
Managed care abuse &
reckless medical claim delays and denials have not only threatened the quality of
our nation’s health care but the abuse has threatened physician survival
as well. More than 40% of medical claims are increasingly being
denied for policy exclusion, lack of medical necessity, above UCR,
bundling & down-coding, retrospective claim review and much more.
The insurance industry has kept
secrets from you for
28 years on
one of the
most important federal laws, ERISA, with their abusive claim
denials. Since ERISA preempts and invalidates your state laws, and you
do not know how ERISA can protect you, you are literally clueless in
proper
claim appeal procedures. The federal government has now published
NEW FEDERAL
CLAIM REGULATIONS, effective January 01, 2002 to empower you and to
protect you against all of the managed care abuses and we are the only
advocates that can teach you
these secrets and give you a
superpower for
your business survival:
The New Federal Claim Regulations (ERISA).
The
New Federal Claim regulation (ERISA), which is now being issued in final form, creates
new & important patient
protections that will ensure you in today's managed care environment
have access to a
faster, fairer, and fuller process for benefit determinations.
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The Most Powerful & only Seminar in the
U.S.
Focused
on Health Care
ERISA
Claim Denials & Appeals
Seminar Schedules
in IL,
NC, PA, VA,
OH, Teleconference
Call (630)-736-2974
FAX to (630) 736-1439
Only One Payment
from Your Denied Claims
May Pay off the Seminar or Book Itself!
Why Not Take Actions to Save 40% of Your Business & Headaches?
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Should
You Wait?
In
a letter from Republican
Congressional leader, John Boehner, to the
Secretary of Labor and
insurance/benefits
industry,
he states that "specifically,
we are concerned about provisions in the final rule that
go even further than the patients' rights
bills
passed by the Congress",
and he urged DOL to revise and delay the entire
claims regulation. |
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Why ERISA Seminars for Health-care Providers??? |
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Health-care claim denial problems have
fundamentally threatened health-care providers business survival;
-
Up to 1/3 health-care claims was completely denied,
rest of them partially and significantly denied. Up to
$500 billion were denied health-care claims in 2000.
-
$1.55
trillion were spent in national health-care in
2002, 14.9% of GDP, out of which $207.2 billion were out-of-pocket
payments, rest of them are health-care claims through third party
reimbursement claims.
-
ERISA regulates about 80% of health-care claims and
is never understood by health-care providers;
-
Traditional Assignment of Benefits Form used in
hospitals and physician's offices does not provide any rights for
physicians to dispute with insurance companies over claim denials
except for only receiving undisputed and paid claims,
according to new government guidance
for new claims procedure, Q-B2;
-
New
Federal Claim Procedure, to be effective January 2002, has
provided health-care providers with
best and maximal protections against improper denials of medical
necessity, usual customary and reasonable, policy exclusion, PPO
discount and pre-existing conditions, Q-C16, Q-C17, Q-D9 & Q-D10;
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Only with proper
understanding of what constitutes a sufficient designation of
authorized representative, as required by
new regulation, to ensure you to obtain
ERISA
rights guaranteed by federal law and to enjoy
maximal
protection to protect your business survival and prosperity.
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Where: |
Vision MRI & CT Of Oak Brook
2425 W. 22nd Street, Suite #105
Oak Brook, Illinois 60523
(click
it for Map & direction)
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For Fax Registration
Click here to Download PDF/Fax verion of Registration Form
For Online Registration or Order
Click here to enter our secured online registration page
Please Specify the Date of Your Seminar on
Registration Form
Seminar Schedules
in IL,
NC, PA, VA,
OH, Teleconference
We now
offer post-seminar teleconference for staff training at $190/hour.
Due to the recent
demand from the
ERISA plans
and TPA's, we're pleased to announce that we also provide
educational and consulting services to the ERISA plans, TPA's and managed
care organizations on
New
Federal Claim/ERISA Regulations and Compliance, however we do not provide any services
involving actual claim dispute or legal advice for any legal matter or
disputes.
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Only One Payment
from Your Denied Claims
May Pay off the Seminar or Book Itself!
Why Not Take Actions to Save 40% of Your Business & Headaches?
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2004.02.19: Text of Letter From Tommy G. Thompson Secretary of
Health and Human Services To Richard J. Davidson, President,
American Hospital Association.
HHS FAQ "Questions On Charges For The Uninsured" (PDF)
HHS FAQ's "regarding offering discounts to
the uninsured" (PDF)
OIG
"HOSPITAL DISCOUNTS OFFERED TO
PATIENTS WHO CANNOT AFFORD TO PAY THEIR HOSPITAL BILLS"
HHS-OIG-Corporate Integrity Agreements
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Employers Audit Workers' Health Claims (Wall Street
Journal via SFGate.com)
Excerpt: "Looking to bring down soaring
health-care costs anywhere they can, more employers are scouring
their health plans for fraud, abuse and simple mistakes by
employees or administrators.
.......The
number of requests for such audits jumped 50 percent last year,
Mr. Farley estimates."
Aetna:
Leading the Fight Against Health Care Fraud
[PDF]
View as HTML
"Thanks to this highly collaborative
relationship, we know how to identify fraud because we know what
to look for.
Medical Fraud
-
Unusual provider billing
practices.
Discrepancy between the
submitted diagnosis and the treatment.
Diagnoses or treatments
that are outside the practitioner’s scope of practice.
Claims that are
resubmitted with coding changes to gain benefits.
Alterations on claim
submissions.
Pressure for quick claim
payment."
Excellus BlueCross BlueShield Fraud Recovery and Prevention
Efforts Net Over $7.5 Million
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"The SIU received approximately
1,000 calls to its Fraud Hotline this past year. Tips are also
received via e-mails and letters to the company."
"The most common types of insurance fraud include:
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Billing for services not provided.
-
Billing for higher-level services
than those actually performed (known as "upcoding.")
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Submitting a claim for a fictitious
physician or ineligible dependent.
-
Falsifying the identity of a
service provider to receive payment for services rendered by a
non-covered and/or non-licensed provider. An example of this is
billing for a massage at a fitness center as licensed physical
therapy.
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Securing prescriptions for
controlled substances that are then re-sold."
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Effective Corporate Compliance Programs for Health Care
Organizations (pdf) (Ernst
& Young)
"An executive summary to our 52-page overview of the
government's efforts to detect and punish health care fraud and
abuse, with guidelines on how organizations can develop an
effective corporate compliance program.
Strengthening Ethical Cultures: The Emerging Role of
Compliance Programs and Officers in Managed Care Organizations
(Ernst
& Young)
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ERISAclaim.com provides unique
and unprecedented seminars on health-care ERISA claims denials and appeals resolution services
for healthcare
providers, physicians, clinics and hospitals. We concentrate on educating
and assisting healthcare providers to become more aware of the most
mystifying federal law, ERISA for past
28 years, and
new federal ERISA regulations for claims
procedures, to be effective January 2002. Our goal is to help you become more effective at prevailing on
improperly denied health care ERISA claims after traditional and
conventional appeal procedures have failed. We will demystify the
complicated federal law, ERISA, which governs most of about 80% of
health-care claims.
Health-care providers need a practical and meaningful way to protect their
rights as well as their patient's rights as originally intended by Congress
in 1974 with
Employee Retirement Income Security Act (ERISA).
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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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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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ERISA &
Health Claim |
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What Is
ERISA and How Does It Affect Patient Rights?
"ERISA was enacted in 1974 to protect the pension and welfare
benefits that employers provide their workers. It currently
covers about 2.5 million health plans and 125 million workers,
retirees, and dependents." |
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ERISA v State Laws |
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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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Former uninsured patients alleged predatory collections
Chicagobusiness.com
Fraud Recovery and Prevention Efforts Net Over $7.5 Million
FAQ/Glossary, Member Services, Preferred Health Network, PHN Online,(
CareFirst BlueChoice, Inc.)
DOL ERISA Talking Points
(BCBSCNY)
BCBS 2004
Edu Programs (pdf)
BCBS2003 Edu Programs (pdf)
Washington Post Examines Health Plans' Increased Scrutiny of
Healthcare Providers' Claims (KaiserNetwork.org)
ABCNEWS.com : Huge Medical Insurance Scam Alleged
"Rarely does the FBI discuss an ongoing investigation. But the
agency made an exception because this scam is so big. Insurance
companies have already been hit with half a billion dollars in
claims."
CNN.com -Transcripts:
A New Plan to Fight Terrorism? A look at Healthcare Fraud
Rent a Patient - Fraud Scheme
(BCBSAL)
KSAT.com - Health - 'Rent-A-Patient' Fraud Under Investigation
"UnitedHealth Group alone said it's told the FBI about 300
allegedly fraudulent Southern California centers."
State of Wisconsin - DOJ News Release
Lautenschlager Announces Public Alert on "Rent a Patient"
Insurance Scams Victimizing Wisconsin Citizens and Businesses
Outpatient surgery centers probed for fraud
(San Jose Mercury News, CA)
'Rent-A-Patient' Fraud Under Investigation
(NBC4.TV, CA)
New Boston podiatrists accused of insurance fraud (AP Wire |
03/11/2004)
TWO ACCUSED IN NEW BOSTON MEDICAL SCAM
(Tyler Morning Telegraph)
USDOJ: Deputy Attorney General: Publications and Documents - -
Health Care Fraud Report Fiscal Year 1998
Payments Go Under a Microscope (washingtonpost.com)
CMS: Comprehensive Error Rate Testing (CERT) Program
(January 15 , 2004)
RECOVERY room
(MLive.com)
USATODAY.com - Hospitals sock uninsured with much bigger bills
A Booster Shot for Uninsured
"Illinois hospitals are hammering out a plan to provide
free or discounted care to the uninsured"
Hospital group examines plan for free care ( Chicagobusiness.com)
""Aggressive collection tactics with uninsured
patients cost a non-profit hospital in Urbana its tax-exempt
status last month. Illinois Attorney General Lisa Madigan is
investigating hospitals’ dealings with the uninsured, and a
Chicago alderman is talking about revoking tax breaks for
hospitals that limit charity care."
Doctor 'scorecards' are proposed (The Wall Street
Journal)
Table of Contents - Health Care Fraud: Enforcement and Compliance -
LawCatalog.com
PROSECUTING AND DEFENDING HEALTH CARE FRAUD CASES, WITH 2003
CUMULATIVE SUPPLEMENT (Author(s):
Michael K. Loucks and
Carol C. Lam)
HEALTH CARE FRAUD AND ABUSE: PRACTICAL PERSPECTIVES, WITH 2003
SUPPLEMENT
Staying Out of
Jail Under ERISA's Bulked-Up Criminal Law Penalites
(Attorneys Russell D. Shurtz and Craig R. Pett) |
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FDA > CDRH >
Database Super Search
"Device Listing Database
Proprietary Device Name:
MASSAGER ( THERAPUTIC, ELECTRIC,
WATER
Common/Generic Device Name:
ASOOTHE/AQUAMED
Classification Name:
MASSAGER, THERAPEUTIC, ELECTRIC
Device
Class:
1
Product Code:
ISA
Regulation Number:
890.5660
Medical Specialty:
Physical Medicine"
Categorization of
Investigational Devices
"... all FDA-approved IDE's
into either Category A (experimental
/ investigational) or
Category
B (nonexperimental/
investigational). An
experimental /
investigational ..."
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