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Moukawsher & Walsh, LLC
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Health Insurance Mandates in the States, 2004: a State-by-State Breakdown ... (PDF) (Council for Affordable Health Insurance)
 
 
 

U.S. Healthcare Crisis Turnaround?

U.S. A.

Drs. & Hospitals Employers

$1.0 Trillion / Year

$$$ ERISA $$$

50% Savings

The Only Company with Compliant Solutions for All of You

03/23/2010

Breaking News

 

President Obama Signed Into the Law the Healthcare Legislation to Revamp Healthcare Reimbursement Laws for All Group Health Plans and Health Care Providers

 

The Final Health Reform Bill Has Been Signed By President Obama Into The Law Of The Land For More Than 95% Americans, As The Most Significant Changes Since Medicare Was Created 45 Years Ago. What Does Obama Healthcare Law Mean To Healthcare Providers And Health Plans? The New Federal Reimbursement Laws Protect Health Care Providers with ERISA Internal And External Appeals, Extended Disclosure And Appeal Rights, New Federal UCR Fee Centers And New Federal Simplified, Uniform Standards For Claim Processing And Appeals. The New Federal Reimbursement Laws Will Eventually Eliminate Most Managed care Abuses

 

New Federal Health Claims & Appeals Laws & Regulations

for 193 Million Americans

Effective 09-23-2010

©2010, Jin Zhou, ERISAclaim.com

Photo of President Gerald R. Ford signing Employee Retirement Income Security Act of 1974

President Obama Signing Health Bill on 03/23/2010

President Gerald R. Ford Signing ERISA on 09/02/1974

New Webinars, Seminars & Certification Classes Announced for New Federal Health Claim Appeals Regulations on July 22, 2010 from HHS, DOL & IRS, Effective On Sept. 23, 2010 for 193 Million Americans

DOL Seal - Link to DOL Home Page

UNITED STATES

DEPARTMENT OF LABOR

(Links to DOL) ©2010, Jin Zhou, ERISAclaim.com

Patient Protection and Affordable Care Act

Statutory Laws [PDF] [PDF]

 

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Affordable Care Act Regulations and Guidance
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Regulations on Internal Claims and Appeals and External Reviews: Interim Final Rule • Amendment to IFR • Corrections •  NAIC Uniform External Review Model Act  • News Release • Fact Sheet •  Public Comments

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Guidance, EOB’s & FAQ’s: TR11-02 • TR11-01 • TR10-02 • TR10-01 • EOB1 • EOB2 • EOB3 • FAQ I • FAQ II • FAQ III •  FAQ IV •  FAQ V • FAQ VI •  Consumer Assistance Programs

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Grandfathered Health Plans: Regulation •  Fact Sheet on Regulation • FAQ’s •  Summary Chart • Model Notice •  Amendment to IFR • Fact Sheet on Amendment

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Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, and Patient Protections: Regulation • Fact Sheet • Patient Protection Model Notice • Lifetime Limits Model Notice • Dependents Model Notice 

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Extension of Coverage For Adult Children:  Regulation •  Fact Sheet • FAQs • IRS Guidance

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Affordable Care Act Compliance Assistance Webcast Series Archive: Part I • Part II

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House Committees Health Insurance Reform at a Glance: Summary • Implementation Timeline • Consumer Protections • For Employers

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White House Web Page on Health Reform

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HHS Health Reform Web Site

Employee Retirement Income Security Act — ERISA

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ERISA Claims Regulation - 29 CFR 2560.503-1: Regulation • FAQ • Fact Sheet • Claims Guide • Claims Card

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ERISA SPD Regulation - 29 CFR 2520.102-3: Amendments to Summary Plan Description Regulations • Fact Sheet • News Release • SPD Rights Fact Sheet • SPD from DOL

 

Health Claims Related Information

bullet Consumer Information on Health Plans
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Webinars, Seminars & Certification Classes for New Federal Health Claim Appeals Regulations

 

ERISAclaim.com - Free Webinars - New Federal Claims & Appeals Regulations, Effective Sept. 23, 2010, for 193 Million Americans

 

ERISAclaim.com: Seminars - 2011 Two-day Basic ERISA Appeal Seminars - Denials and Overpayment Appeals

 

ERISAclaim.com - 2011 PPACA & ERISA Claim Specialist Certification Programs in Chicago, Illinois

 

ERISAclaim.com:  Create An Appeal Department for Your Hospital or Practice (In-house, onsite ERISA Claim Specialist Certification Programs)

 

Welcome

 

ERISAclaim.com with its principal and founder, Dr. Jin Zhou, is committed to providing unique and practical solutions to our nation's health care crisis, in case the Congress and the President of the United States fail to stop our health-care crisis, probable health care crash and future federal budget deficits of $44.2 trilion;

 

We will provide educational and consulting solutions to healthcare providers, clinics and hospitals for maximum reimbursement or crisis turnaround only through compliance of ERISA;

We will provide educational and consulting solutions to employers/plan sponsors, insurers and TPA's with compliance assistance to minimize administrative costs and risks through compliance of ERISA;

 

We will provide educational and consulting solutions to the nation to establish or restore the hope, faith and the Law & Order  for our health-care system through education and compliance of ERISA, the federal law designed to regulate about 80% of the health-care claims and 60% of the U.S. health-care expenditure, ERISA is the only "nuclear power" capable of stopping our escalating health-care costs. Compliance is the only common ground for everyone, and it is the only way that we can bail out of our worst health-care crisis since World War II.

 

Our strategy is to solve US health-care crisis through:

 

  1. Scientific identification of the most accurate causation for skyrocketing medical inflation and fundamental failure of US health care delivery system - ERISA Failure;

  2. Identification of common ground for everyone involved, governing federal law for employer-sponsored health-care system that has been already on the book for the past 30 years - ERISA; and

  3. Providing a solution to

 

ό     Establish Prudent "Personal Responsibility" without Eliminating Employer-Sponsored Health-Care System and without "Skipping Necessary Health Care" and "Personal Bankruptcy";

ό      Keep Employer-Sponsored Health-Care System with Quality Health Care but without Skyrocketing Medical Cost Disaster.


Our mission is to prevent another "Failure of Imagination" in US healthcare crisis triggered economic recession or even disaster, and
"John Q. ERISA Enforcement"!

 

 

New Webinars, Seminars & Certification Classes Announced for New Federal Health Claim Appeals Regulations on July 22, 2010 from HHS, DOL & Treasury    08/05/2010, Hanover Park, IL

New Webinars, Seminars & Certification Classes Were Announced by ERISAclaim.com for New Federal Appeals Regulations Issued on July 22, 2010 by HHS, DOL & Treasury for 193 million Americans. Effective 09/23/2010, New Federal Reimbursement Laws Mandate ERISA Internal Appeals and NAIC External Appeals For All Group and Individual plans With Six New & Most Powerful Consumer Protections

 

ERISAclaim.com - 2009 - 2010 Claim Denial & Overpayment Dispute Two-day ERISA Appeal Seminars,

 

ERISAclaim.com - 2010 ERISA Claim Specialist Certification Programs in Chicago, Illinois

 

New ERISA Appeal Book with 2010 Major Updates  $450  & $150 (Updates only with previous purchase)

 

ERISAclaim.com - ERISA Litigation Support, Facts + Laws + Strategies = Winning Lawsuit When Inevitable

 

ERISAclaim.com - Free ERISA Webinar, The Beginning for $6 Trillion Healthcare Denial Management Market

 

ERISAclaim.com Press Release

 

ERISAclaim.com Announced the Nation's First Certification Program for the ERISA Claim Appeal Specialist for Healthcare Providers and Managed-Care Payers, 10-13-2009, Hanover Park, IL

 

ERISAclaim.com Announced 2010 ERISA Seminars for Healthcare Overpayment and Claim Denial Appeals for the $6 Trillion Healthcare Denial Management Market. 10-14-2009, Hanover Park, IL

 

 

Unanimous US Supreme Court Ruling

In US Health Care Crisis

by Jin Zhou, 02/11/2005

© 2005, Jin Zhou, ERISAclaim.com


Managed-Care Nightmares?

Health-Care Crisis without True Solutions?

 

What Does an 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.

 

How Can Anyone in USA, from Congress to General Motor to the White House, from Industry Experts to Patient Advocates, Solve US Health Care Crisis without Even Thinking of ERISA?


"Failure of Imagination" As a Nation Is the Real Tragedy

 

ERISAclaim.com - Supreme Court Managed Care ERISA Watch

 

Unanimous US Supreme Court Ruling In US Health Care Crisis

 

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."

 

 

 

Discount for March 2005: $35
 

$450 ERISA CD Book

ERISA Claim Appeal Books & Systems

Click here or the CD-Picture to enter our Secured Online Order page

 

With New 2005 Update (including New ERISA Assignment Form Required for ERISA Appeals, DOL, FAQ, B2-3)

 

ERISA Failure Syndrome

U.S. Healthcare Crisis Trilogy

(Copyright © 2004 by Jin Zhou,  ERISAclaim.com)

 

ERISA
Medical Killing
ERISA
Medical Inflation
ERISA
Insurance Robbery
"Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance

Read Making a Killing

?

 

?

Bar graph showing trends in hospital charges and revenues in California from 1995-2002

 

 

?

 

?

GAO-04-312

?
?

American Job ExportING!

Mass layoffs up in January 2004

Weirton Steel cancels 10,000

GM: $67.5 billion in 2003

One Nation under Debt: U..S. economy threatened by aging of America

 

Healthcare Disaster at Fault Verdict Index:

U.S. Government 30%

U.S. Employers & Insurers 30%

Healthcare Providers 30%

Consumers 10%

(ERISA Failure + Managed-Care) Destroyed US Healthcare
(ERISA Failure + Managed-Care + HSA) Invite US Federal Budget Deficit & Social Security Disasters = 100X 9/11 Attacks

 

GAO: Current and Emerging Fiscal and Retirement Security Challenges, American Benefits Council/MetLife Conference, Washington, DC, on January 14, 2005

  1. Rising Health care Costs Have Many Implications (Direct)

  2. Rising Healthcare Costs Have Many Implications (Indirect)

 

Rx-1  $$$$$$$$$ERISA"Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance
$$$$$$$$$$  Rx-2

 

 

 

 

 

DOJ: Criminal Resource Manual 2432 Coercive or Fraudulent Interference with ERISA Rights -- 29 U.S.C. 1141

2432 Coercive or Fraudulent Interference with ERISA Rights -- 29 U.S.C. 1141

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

ERISA 510 29 USC 1140 Interference with protected rights.
ERISA 511 29 USC 1141 Coercive interference.

 

ERISAclaim.com

Happy
Birthday Sept. 2,
1974
30th
Birthday

 

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."

 

ERISA Shield Explosion!!!

ERISA Patient's Bill of Right from Supreme Court

(Copyright © 2004 by Jin Zhou,  ERISAclaim.com)

04/28/2004

This will change entire health care and litigation landscape.

Click here for more details

 

 

The Root of U. S. Healthcare Crisis

Jin Zhou, ERISAclaim.com

The Hearing at Senate Committee on Finance on 3-3-04, [View Video "Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance
or Transcript (PDF) (KaiserNetwork.org)]  revealed the mechanism, nature and extent of ERISA failure and nonenforcement as the reasons for "Growth in Bogus Health Insurance Plans Targeting Desperate Small Business Owners", as being concluded as "No the results are not good. It’s a tragedy." by Ann Combs, assistant secretary of DOL. The mechanism, nature and extent of ERISA failure and nonenforcement as presented at the Hearing are universally true and applicable to all health care claim denials and delays in managed care environment from all employer sponsored health plans as the root of U. S. healthcare crisis.

 

This is a 911 call on "healthcare 9/11 disaster"!

THE 9/11 COMMISSION REPORT (pdf)

 

 

50% Savings in
Healthcare Costs for
Employers, Insurers & TPA's

U. S. Health-care Crisis Turnaround

Brainstorming

for Executives

ERISA Claims Certification Class
(Denial Management)

Claim Denial & 
Appeal Network

Claim Recovery

Appeal Books

Seminars

Consulting

Reimbursement Crisis? Contingency Recovery Service for Dead, Difficult  and Hopeless Accounts from Denied Medical/ERISA Claims In past 3 Years, This Could Be up to 20-40% of Your Revenue.

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

 
for Health Care Providers, Physicians, Clinics and Hospitals.
(2003 Update Free Download)

We now offer post-seminar teleconference for staff training at $190/hour.

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

Stop Managed Care Abusive Claim Delays & Denials!

Getting Paid with New Federal Claim (ERISA) Rules

Maximal Reimbursement
or
Crisis Turnaround to Get Paid
 Concentrating on ERISA Healthcare Claim Denials And Appeals When Traditional and Conventional Appeal Procedures All Failed  Because ERISA Preempts Your State Laws.

 

ERISA OVERHAUL OF U.S. HEALTHCARE FOR SURVIVAL

 

"Zhou's Model of Prudent Health Care"

Are All Consultants Corrupt? (Fast Company)

USA: GM chief talks health care as Republicans convene: Auto News

"Wagoner reportedly said much of the discussion in Washington tends to centre around a complete, free-market system on one extreme, and a national health care programme [similar to the UK’s National Health Service] on the other.

 

"I suspect we're not going to end up with either one of those solutions," he told the Associated Press. "So if we could get people working on stuff in the middle ... I think there'd be some real improvements made."

        Jin Zhou Identifies "ERISA Failure" That Killed U.S. Healthcare

"Failure of Imagination" Again?

 

ASO+HMO+PPO-SPD=$1.8 Trillion/Y US Healthcare Crisis

 

ERISA+SPD-HMO-PPO-ASO=50% Savings

 

The First Overhaul for U.S. Health care and GM Is to ERISA-Overhaul GM Health Care Model with Followings:

  1. ERISA Compliant SPD with Complete Benefits Coverage, Limits & Exclusions;

  2. ERISA Compliant Claims Procedure as the Only Rule for Every One;

  3. Elimination of Any Third-Party Managed Care Contracts, UCR & "Medical Necessity"

GM Current Model: $5.1 billion/yr, $1,400/vehicle)
(GM says health care obligation hit $67.5 billion in 2003)

Rx-1  $$$$$$$$$ERISA"Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance
$$$$$$$$$$  Rx-2

General Motors National Benefit Center

Health Spending Projections Through 2013

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)

U.S. Health-care Crisis & ERISA Criminal Enforcement

CBO's analysis of the President's budgetary proposals for fiscal year 2005

Fact Sheet: Affordable Health Care for America's Families (White House)

 

 

DOL-Reporting and Disclosure Guide for Employee Benefit Plans (pdf)
Compliance Assistance for Group Health Plans (Top 15 Tips)

950,000 MD's Settled With Aetna & Cigna on ERISA
"Aetna and CIGNA Settlement Secrets"
ERISA Certification Programs for Maximal Reimbursement

What You Should Know about Filing Your Health Benefits Claim
HIPAA Nondiscrimination Requirements Frequently Asked Questions

 

 

 

 

 

ERISA Power Guides
(Copyright © 2004 by Jin Zhou,  ERISAclaim.com)

What You Should Know about Filing
Your Health Benefits Claim (Claims Card)

Filing A Claim For Your Health Or Disability Benefits (PDF)

Patient's Rights Claims Procedure Regulation (Fact Sheet)
Benefit Claims Procedure Regulation (FAQ) (PDF)
New Federal Claim Regulation (Final Rule) (PDF)
Amendments to Summary Plan Description Regulations

(Final Rule) (PDF)

   

New & Interactive From DOL
New @ elaws

Health Benefits Advisor

DOL/EBSA Organization Chart/Regional and District EBSA Offices | By Topic | By Audience | By Organization | By Location  

 

 

 

 

 

Department of Labor

"A group health plan is an employee welfare benefit plan established or maintained by an employer or by an employee organization (such as a union), or both, that provides medical care for participants or their dependents directly or through insurance, reimbursement, or otherwise.
 

Most private sector health plans are covered by the Employee Retirement Income Security Act (ERISA). Among other things, ERISA provides protections for participants and beneficiaries in employee benefit plans (participant rights), including providing access to plan information. Also, those individuals who manage plans (and other fiduciaries) must meet certain standards of conduct under the fiduciary responsibilities specified in the law."

 

 

 

Statutes (United States Code) 
ERISA - Title 29, Chapter 18. 

        Selected links:

Sec. 1002.
Definitions

Sec. 1003.
Coverage

Sec. 1022.
Summary plan description

Sec. 1027.

Retention of records
Sec. 1104.
Fiduciary duties

Sec.1106.

Prohibited transactions

Sec. 1140.
Interference with protected rights

Sec. 1141.
Coercive interference

part 7
group health plan requirements

 

 

Code of Federal Regulations

Codified in Title 29 of the Code of Federal Regulations:

Regulations

        Selected links:

2520.102-3 Contents of summary plan description.
2560.503-1 

Claims procedure.

 

 

 

ERISA & Claim

Aetna Video Shows ERISA Patients Mistreated

 

"According to the video, when faced with claims for identical medical problems, Aetna separates the claims where no damages are available - those subject to the federal Employee Retirement Income Security Act, or ERISA - from non-ERISA claims, where consumers can sue.1 2"

 

Aetna ERISA Settlemnt with 950,000 MD's

 

 

 

ERISA Laws/Rules

ERISA in the United States Code: Cross-reference table, table of contents

 

ERISA in US CODE

 

 

 

HHS OCR
Home Page

 

HIPAA Privacy

 

Office for Civil Rights - HIPAA

OCR Guidance Explaining Significant Aspects of the Privacy Rule- December 4, 2002

 

 
Working Families' Health Insurance Coverage, 1997-2001 (Center for Studying Health System Change)
 

"Of the 189 million nonelderly people in working families in 2001, 77.5 percent, or 146 million, had employer coverage,.."

 

 

 

 

Opinion: The Coming Crash in Health Care (Fortune.com)
"Thus it may come as a surprise to learn that the managed-care industry is dying. Oops, did we spill the beans so soon? Well, so be it. Managed care is on the way out."

 

 

 

 
   

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Phone (630) 736-2974 - Fax (630) 736-1439

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