ERISAclaim.com

 

Death of Managed Care
Order ] FAQ & Disclaimer ] Copyright ] New Partners ] Discussion ]
 

USHealthcareCrisis.com

 

 
Products & Services
Press Release
What's New
PPACA for CFOs
Free Webinars
Seminars
Certification Program
ERISA Appeal Dept
Health Reform Laws
Pre-Payment Review Denials
Non-PPO Checks?
Embezzlement Recovery
ERISA for Hospitals
"Overpayment" Refund
ERISA Litigation Support
ERISA or PPO
ERISA or non-ERISA Appeal?
PPO + ERISA Lawsuit
Overpayment & SIU
Prompt Pay Crisis & Rx
Medical Claim Denials
Downcoding & Bundling
Pre-existing Cond. Denial
Death of Managed Care
Healthcare Crisis Bailout
Medicare RAC Overpayment
CMS New Appeal Rules
ERISA & Your Money
ERISA & Your Insanity
On-site Education
ERISA, Who?
Rx for GM Health Crisis
Medical Device Makers
Executive Brainstorming
"Failure of Imagination"
U.S. Healthcare Crisis Rx
Employers, Insurers, TPA's
Integrated Systems
ERISA Appeal 1-2-3
ERISA Demystified
Medicare & ERISA
HSA & ERISA
ERISA Criminal Enforcement
Consulting Service
Claim Recovery
Appeal Networks
950,000 MD's & ERISA
DOL Final Rules
DOL New Guidance
Supreme Court
Court Watch
Company Info
Contact Us

 

 

 

Advertisement

 

Moukawsher & Walsh, LLC
Pension and Employee Benefit Law

Benefitlawyers.com

 
 

 
 
 
 
 

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

Rx-1  $$$$$$$$$ERISA"Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance
$$$$$$$$$$  Rx-2
US Supreme Court Visits ERISAclaim.com

at 11:57:03 AM on Friday, November 21, 2003

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]

 

 

Employee Retirement Income Security Act — ERISA

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 - 2010 Two-day Basic ERISA Appeal Seminars - Denials and Overpayment Appeals

 

ERISAclaim.com - 2010 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)

 

 

 THE DEATH OF MANAGED-CARE MODEL

& HEALTH INSURANCE INDUSTRY UCR FRAUD

 

© JIN ZHOU, President,

ERISAclaim.com

March 27, 2009

  

The managed-care model for US healthcare industry is dead after  it has failed to contain skyrocketing healthcare costs and medical inflation in the past decade as originally intended and has resulted in more than 48 million Americans uninsured, in the wake of litigation explosion by healthcare providers and consumers against managed-care entities and recent investigation conducted by the Attorney General of New York which concluded that for a number of years, the insurance industry has systematically under-estimated the out-of-network reimbursement rates it pays its policy holders, costing consumers billions of dollars in excessive out-of-pocket costs, with subsequent settlements by many industry managed-care insurers and more litigations for the rest, and the Congressional investigation now, on March 26, 2009, the Senate Committee on Commerce, Science, and Transportation announces a full committee hearing on Deceptive Health Insurance Industry Practices – Are Consumers Getting What They Paid For?.

 

26th at 10:30 AM PART I: Deceptive Health Insurance Industry Practices – Are Consumers Getting What They Paid For?

Majority Statements by John D. Rockefeller, IV

pdf Document  Mr. Chuck Bell's Testimony, Consumers Union

pdf Document  Dr. Mary Jerome's Testimony, Yonkers New York

pdf Document  Ms. Linda A. Lacewell's Testimony, NY AG

pdf Document  Dr. Nancy H. Nielsen's Testimony, AMA

View Archive Webcast on 03/26/2009

View Archive Webcast on 03/31/2009

pdf Document  3_31_09 Hearing Exhibits

03/26/2009 - Press Release: Chairman Rockefeller Holds First Oversight and Investigations Hearing on Deceptive Health Insurance Industry Policies

03/31/2009 - Senator Investigates Health Insurers’ Out-of-Network Rate Practices

03/31/20009 - Chairman Rockefeller's Opening Remarks for Part II of Deceptive Health Insurance Hearing

 

31st at 10:00 AM PART II: Deceptive Health Insurance Industry Practices – Are Consumers Getting What They Paid For?

Majority Statements by John D. Rockefeller, IV

pdf Document  Mr. Stephen J. Hemsley's Testimony, UHC

pdf Document  Mr. Andy Slavitt's Testimony, Ingenix

 

 

The  managed-care model gained its power and market control decades ago by private managed-care contracting directly with healthcare providers  initially through  HMO model's capitated fee schedule to reduce unnecessary healthcare services,  subsequently through PPO model which penalizing out-of-network provider access through UCR (usual, customary and reasonable) fee schedule manipulation and in network PPO fee reduction through "voluntary" contracting in exchange with wholesale referral of patients. With initial short-term success from both HMO and PPO models, yet the market continued to deteriorate with uncontrolled skyrocketing healthcare costs while managed-care contracting replaced, hijacked or otherwise substituted or replaced almost all public policies, regulatory enforcement in both federal laws, ERISA, and state insurance laws, managed-care and consumer protection laws for medical necessity review (utilization review) and network access by consumers. With its continued failure  to contain health-care costs through gatekeeping medical necessity reviewers for HMO model, and medical necessity review coupled with PPO  contracting fee reduction and non-PPO UCR reduction for PPO model, managed-care industry responded to with initial POS ( Point of Service) and subsequent P4P (Pay-For-Performance) in an attempt to save managed-care model. Ultimately managed-care model has completely failed to contain US healthcare costs with skyrocketing medical inflation and unprecedented 48 million uninsured Americans.

 

Now that non-PPO UCR fee schedule of managed care model will soon be a public or regulatory matter, as UnitedHealth said its statements: “Once the new database is operational, the Ingenix databases will be closed and not available to any health insurer,” and as Senator Rockefeller says his goal is "to ensure that the practice of underpaying for out-of-network doctor visits is ended in every state, not just New York".

 

Once managed care model's out-of-network UCR fee schedules no longer hold water in public, regulatory and legislative environment, the all in-network PPO savings for entire managed care attractions will   disappear. Managed care model for U.S. healthcare is now completely dead, with market symptoms as 95,000 doctor's class action lawsuit, in critical condition with New York Attorney General's Investigation of and settlement with UnitedHealthcare, and obituary and funeral notice with Senate Hearing on March 26, 2009: "Deceptive Health Insurance Industry Practices – Are Consumers Getting What They Paid For?" and Mr. Stephen J. Hemsley's Testimony as President and Chief Executive Officer UnitedHealth Group before  The Senate Committee on Commerce, Science, and Transportation.

 

Goodbye to Managed Care Model for U.S. healthcare industry!

 

Managed-Care Model, through private contracting for USA health industry for decades by complete disregard of federal law, ERISA, which was truly intended by Congress to completely govern and control healthcare costs and reimbursement dispute for more than 90% of non-Medicare claims, and through escaping state laws in managed-care and consumer protections, has been completely dead from its heart and core for its power to contain or control health-care costs and improve healthcare quality but still with very enticing appearance for any blind crusader to resuscitate healthcare industry.

 

One of the worst tragedy or mistake by USA for healthcare industry and US economy, similar to 9/11 disaster, is the "Failure of Imagination", as concluded by Congressional 9/11 Commission.  34 years ago in 1974, Congress has intended and decided to enact a federal law, ERISA (Employee Retirement Income Security Act of 1974), to completely and 100%  regulate and control healthcare claim reimbursement and dispute for 160  to 175 million working Americans covered under employer-sponsored plans. As clearly as United States Supreme Court interpreted (Aetna v. Davila) that ERISA completely (100%) regulates and governs all of the money dispute as benefits denials from employer-sponsored  health plans and (100%) completely preempts or validates any and all state laws and managed care contracting when a dispute is "denial of benefits" with ERISA plans. However entire USA has completely failed to understand, or imagine, that Congress intended to use public policy, ERISA law, instead of managed-care private contracting, to contain health-care costs and resolve health-care money disputes and access to quality healthcare. A "Failure of Imagination"  again for U.S. healthcare and economy, in addition to homeland security and antiterrorist, as explained and concluded by  Congressional 9/11  Commission.

 

While New York State attorney general at the state level and Senate committee at federal level are investigating and concluding a systematic failure and  fraud by health-insurance industry policies, On July 25, 2008, President Obama expressed his frustrations in US DOL's failure to enforce US labor laws in general in his presidential campaign  last year, he now appointed a new law professor extremely experienced in ERISA to head the USDOL's EBSA, a division of DOL in charge of ERISA claim regulation, after decades of DOL's total failure in federal regulatory enforcement of ERISA Claim Regulation through a symbolic enforcement with pure "Voluntary Compliance Assistance" for any and all violators with little or no enforcement under the Congressional Leaders' Non-Obama Guidance.  Although a strong indication that Obama administration is heading the right direction to avoid "Failure of Imagination"  again, to enforce ERISA claim regulation as intended by Congress and interpreted by United States Supreme Court, to truly save health care costs and reduce uninsured Americans, whether Obama administration will succeed in this healthcare and managed-care crisis turnaround remains to be seen.

 

For the rest of world on the  U.S. healthcare landscape at this critical juncture of U.S.  economic recession and healthcare critical condition in ICU when managed-care model that we have married to for so long being dead and 34-year-old statutory spouse of ERISA (may a girl's name) yet totally unknown to us, we must educate ourselves and turn to ERISA  to be the first one on the block or on the top of the this picture when the next US healthcare chapter is out of Chapter 11.

 

Dr. Jin Zhou, the president of ERISAclaim.com, respectively invite you to review the following breaking developments and statutory facts, and draw your own conclusions based on the facts and laws.

 

ERISA Completely (100%) Regulates, Governs and Controls  Pricing and Payment or Cost for Employer Sponsored Health Plans for More than 90% of Non-Medicare Claims, and ERISA Mandates UCR Fee Schedule Disclosures (DOL ERISA FAQ B5)

 

Opinion of the U.S. Supreme Court

06/21/04

 

Aetna Health Inc. v. Davila

 

"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."

 

$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

 

B-5: For purposes of furnishing relevant documents to a claimant, what kind of disclosure is required to demonstrate compliance with the administrative processes and safeguards required to ensure and verify appropriately consistent decision making in making the benefit determination?

 

What documents will be required to be disclosed will depend on the particular processes and safeguards that a plan has established and maintains to ensure and verify appropriately consistent decision making. See 65 FR at 70252. The department does not anticipate new documents being developed solely to comply with this disclosure requirement. Rather, the department anticipates that claimants who request this disclosure will be provided with what the plan actually used, in the case of the specific claim denial, to satisfy this requirement. The plan could, for example, provide the specific plan rules or guidelines governing the application of specific protocols, criteria, rate tables, fee schedules, etc. to claims like the claim at issue, or the specific checklist or cross-checking document that served to affirm that the plan rules or guidelines were appropriately applied to the claimant’s claim. Plans are not required to disclose other claimants’ individual records or information specific to the resolution of other claims in order to comply with this requirement. See § 2560.503-1(m)(8)(iii).  See question D-12."

<http://www.dol.gov/ebsa/faqs/faq_claims_proc_reg.html>

 

==========================================

 

Excerpt: "President Obama on Tuesday during a prime-time news conference linked issues within the U.S. budget in part to high health care costs, stating that 'almost every single person' who has examined the nation's budget has concluded that the government must find a way to reduce health care costs, the Washington Post reports (Shear/Wilson, Washington Post, 3/25)."

Fixing healthcare without addressing ERISA, the law 100% governing more than 90% of non-Medicare claims in USA, is Impossible - Jin Zhou

 

 

The White House News: New ERISA Chief for USA:  

 

"Phyllis C. Borzi, Nominee for Assistant Secretary of Labor for Employee Benefits Security, Department of Labor"

 

 

The White House News: New ERISA Chief for USA:  

 

"Phyllis C. Borzi, Nominee for Assistant Secretary of Labor for Employee Benefits Security, Department of Labor"

 

Excerpt: "Until January 1995, [Phyllis] Borzi served as pension and employee benefit counsel for the U.S. House of Representatives, Subcommittee on Labor-Management Relations of the Committee on Education and Labor. She was on the Committee staff for 16 years. . . . . Borzi has published numerous articles on ERISA, health care law and policy and retirement security issues and is a frequent speaker on programs sponsored by legal, professional, business, consumer and state and local governmental organizations. An active member of the American Bar Association, Borzi is the current chair of the ABA's Joint Committee on Employee Benefits . . . ."

Excerpt: "President Obama on Tuesday during a prime-time news conference linked issues within the U.S. budget in part to high health care costs, stating that 'almost every single person' who has examined the nation's budget has concluded that the government must find a way to reduce health care costs, the Washington Post reports (Shear/Wilson, Washington Post, 3/25)."

Comments from Jin Zhou:

 

Fixing healthcare without addressing ERISA, the law 100% governing more than 90% of non-Medicare claims in USA, is Impossible - Jin Zhou

 

ERISA laws will be definitely enforced by this new ERISA Chief.....

 

ERISA appeals and practice will mean more than ever before....

 

 

Thursday, 10:30 AM, March 26, 2009, The Senate Committee on Commerce, Science, and Transportation announces a full committee hearing on Deceptive Health Insurance Industry Practices – Are Consumers Getting What They Paid For

 

26th at 10:30 AM PART I: Deceptive Health Insurance Industry Practices – Are Consumers Getting What They Paid For?

Majority Statements by John D. Rockefeller, IV

pdf Document  Mr. Chuck Bell's Testimony, Consumers Union

pdf Document  Dr. Mary Jerome's Testimony, Yonkers New York

pdf Document  Ms. Linda A. Lacewell's Testimony, NY AG

pdf Document  Dr. Nancy H. Nielsen's Testimony, AMA

View Archive Webcast on 03/26/2009

View Archive Webcast on 03/31/2009

pdf Document  3_31_09 Hearing Exhibits

03/26/2009 - Press Release: Chairman Rockefeller Holds First Oversight and Investigations Hearing on Deceptive Health Insurance Industry Policies

03/31/2009 - Senator Investigates Health Insurers’ Out-of-Network Rate Practices

03/31/20009 - Chairman Rockefeller's Opening Remarks for Part II of Deceptive Health Insurance Hearing

 

31st at 10:00 AM PART II: Deceptive Health Insurance Industry Practices – Are Consumers Getting What They Paid For?

Majority Statements by John D. Rockefeller, IV

pdf Document  Mr. Stephen J. Hemsley's Testimony, UHC

pdf Document  Mr. Andy Slavitt's Testimony, Ingenix

 

 

Press ReleasesPress Releases
For Immediate Release
03/26/09

 
Contact: Jena Longo - Democratic Deputy Communications Director 202.224.7824
Email This
Print This
Chairman Rockefeller Holds First Oversight and Investigations Hearing on Deceptive Health Insurance Industry Policies
 

WASHINGTON, D.C. – The Senate Committee on Commerce, Science, and Transportation held a full committee hearing today on “Deceptive Health Insurance Industry Practices– Are Consumers Getting What They Paid For?”

 

Today was the first of two hearings examining how the health insurance industry reimburses consumers for health care services.  These hearings focus on the way the industry calculates “usual, customary and reasonable” reimbursement rates for consumers who choose to receive care from out-of-network doctors and other health care providers. 

 

A recent investigation conducted by the Attorney General of New York concluded that for a number of years, the insurance industry has systematically under-estimated the out-of-network reimbursement rates it pays its policy holders, costing consumers billions of dollars in excessive out-of-pocket costs.  The victims of this deceptive practice – more than 100 million Americans who pay for health insurance coverage that allows them to go outside of their provider network for medical care.

 

Key Quotes From Today’s Hearing:

 

• “The health insurance industry has been promising to pay a certain share of consumers’ medical bills, but then they have been rigging health charge data to avoid paying their fair share,” Rockefeller said.  “The result is that billions of dollars in health care costs have been unfairly shifted to millions of American consumers.”

 

• In written testimony, Dr. Mary Jerome, a cancer patient, shared her personal experience with unfair practices and fees: “When I was diagnosed with cancer, I thought the most difficult hurdle I would face would be the disease. Little did I know, that dealing with my insurance company would be my greater battle, because unknown to me, they were operating with deceptive methods of reimbursement. I had to battle cancer – and I am still battling it – and I had to battle my insurance company to try and get fair coverage. It was almost too much to bear.

 

• “Nationwide, medical costs are the leading cause of individual bankruptcy, even though the individual usually had insurance,” testified Linda Lacewell, representing the Office of the New York State Attorney General. “Fraudulent under-reimbursement for insured Americans is one part of this negative equation for consumers.”

 

• Representing the Consumers Union, Chuck Bell explained: “The key problem with the out-of-network reimbursement system is that the UCR (“usual, customary and reasonable”) rates were not calculated in a fair and impartial way. For the last ten years or so, the primary databases that are used by insurers to determine “usual, customary and reasonable” rates have been owned by Ingenix, a wholly-owned subsidiary of UnitedHealth Group.”

 

• Dr. Nancy Nielsen, president of the AMA, was joined by the Medical Society of the State of New York, the Missouri State Medical Association and several other parties in initiating a class-action lawsuit against United Health Group for using skewed data to determine out-of-network payment rates.  “After nearly a decade of litigation, the AMA is very pleased that United Health Group recognized the importance of restoring its relationship with patients and physicians and is settling the AMA’s lawsuit by agreeing to pay $350 million toward reimbursing the patients and physicians it short-changed, and by confirming in federal court its separate agreement with New York Attorney General Cuomo to end the use of this database and trust its repair and operation to a not-for-profit institution,” Dr. Nielsen testified.

 

***On Tuesday, March 31, 2009 at 10:00 a.m., the full committee will conduct the second part of this hearing on deceptive health industry practices with testimony from Mr. Stephen J. Hemsley, President and Chief Executive Officer of UnitedHealth Group and Mr. Andy Slavitt, Chief Executive Officer of Ingenix.***


###

 

 

 

HearingsHearings

PART I: Deceptive Health Insurance Industry Practices – Are Consumers Getting What They Paid For?

Thursday, March 26, 2009
10:30 AM
 
SR - 253
View Archive Webcast
 

Washington, DC-- The Senate Committee on Commerce, Science, and Transportation announces a full committee hearing on Deceptive Health Insurance Industry Practices – Are Consumers Getting What They Paid For? The Committee will be holding two hearings examining how the health insurance industry reimburses consumers for health care services. These hearings will focus on the way the industry calculates “usual and customary” reimbursement rates for consumers who choose to receive care from out-of-network doctors and other health care providers. A recent investigation conducted by the Attorney General of New York concluded that for a number of years, the insurance industry has systematically under-estimated the out-of-network reimbursement rates it pays its policy holders, costing consumers billions of dollars in excessive out-of-pocket costs. The Committee will take testimony about this investigation and about its implications for consumers nationwide.

 

Majority Statements

John D. Rockefeller, IV

 

Witnesses

Opening Remarks

Panel 1

Chuck Bell
Programs Director
Consumers Union

 

Dr. Mary Jerome
Yonkers
New York

 

Linda A. Lacewell
Counsel for Economic and Social Justice and Head of the Healthcare Industry Taskforce
Office of the New York State Attorney General

Dr. Nancy H. Nielsen
President
American Medical Association

 

 

 

 

Statement of John D. Rockefeller, IV
Hearing: PART I: Deceptive Health Insurance Industry Practices – Are Consumers Getting What They Paid For?
Thursday, March 26, 2009

 

Opening Statement – John D. (Jay) Rockefeller IV, Chairman

Good Morning. Today’s hearing is the first of two hearings we are holding to look at a deceptive payment practice that the health insurance industry has gotten away with for the last decade, maybe even longer.

The victims of this deceptive practice were probably most of the people sitting in this hearing room today, along with the more than 100 million Americans who pay for health insurance coverage that allows them to go outside of their provider network for medical care.

Having the ability to get health care services outside of their network is an important option for American consumers, and it’s an option they pay for – in the form of higher premiums, higher deductibles, and higher co-insurance payments.

We were scheduled to hear today from Dr. Mary Jerome, a resident of Yonkers, New York, who has been fighting ovarian cancer since 2006.

Dr. Jerome was not feeling well enough to coming down to Washington today to testify, but she was kind enough to send us her testimony. I ask unanimous consent to make her testimony part of the hearing record.

According to her testimony, Dr. Jerome received her health care coverage through a Point of Service plan, which encouraged her to get care within a provider network, but also allowed her to see out-of-network providers if necessary.

Here’s what she says in her testimony: “I had always been confident that paying for the out-of-network option provided peace of mind with respect to the financial burdens associated with catastrophic medical costs.”

After her cancer diagnosis, Dr. Jerome and her in-network primary care physician decided she needed to be treated by a health care provider that was outside of her network, the Memorial Sloan Kettering Cancer Center in New York City.

Dr. Jerome knew she was going to have to pay some portion of these costs out of her own pocket, but she also assumed in good faith that the treatment was going to be covered by her insurance.

What we are going to learn today is that American consumers like Dr. Jerome – people who have been paying higher premiums for the choice to see out-of-network doctors - have not been getting what they paid for.

We are going to hear testimony suggesting that the health insurance industry has been systematically lowballing American consumers.

They have been promising to pay a certain share of consumers’ medical bills, but then they have been rigging health charge data to avoid paying their fair share.

The result is that billions of dollars in health care costs have been unfairly shifted to Dr. Jerome and millions of other American consumers like her.

Here’s how it works: the insurance companies generally promise to reimburse out-of-network medical services at what they refer to in the industry as the “usual, customary, and reasonable” rate.

Well, the problem is that it’s been the insurance industry who’s been deciding what “usual, customary, and reasonable” means. Consumers haven’t had any input, doctors and other health care providers haven’t had any input. Only the insurance companies have been getting to decide what’s reasonable.

That’s like letting the fox define “usual, customary and reasonable” in the henhouse.

The good news is that thanks to a series of lawsuits and a year-long investigation by the New York Attorney General’s office, the insurance companies that operate in New York – including, most importantly, UnitedHealth Group and its medical information subsidiary, Ingenix - have been forced to change the way they do business.

Our goal for today is to get an update on how the reforms proposed in New York are being implemented, and to understand how the deceptive practices uncovered in New York have been harming consumers in the other 49 states.

I am looking forward to this testimony, especially at a time when we are once again taking a good, hard look at our country’s health care system.

I would like to finally note that missing from our hearing today is one group of stakeholders who played an indispensable role in creating and perpetuating this unfair reimbursement system, but who will also play an essential role in changing it – the insurance industry.

On March 9, 2009, I invited the CEOs of UnitedHealth Group and Ingenix to testify at this hearing today so we could hear their side of the story. Because UnitedHealth told us that their CEO, Mr. Stephen Hemsley, was not available to testify today, we agreed to hold a second hearing next week.

At 10 AM next Tuesday, March 31, 2009, we will be holding a hearing during which we hope to gain a better understanding of the insurers’ perspective.

I now yield to the Ranking Member for her opening statement.

###

 

 

01/13/2009


Attorney General Cuomo Announces Historic Nationwide Health Insurance Reform; Ends Practice Of Manipulating Rates To Overcharge Patients By Hundreds Of Millions Of Dollars

 

 

Breaking News in 2009 for Healthcare Reimbursement

© JIN ZHOU, President,

ERISAclaim.com

Jan. 13, 2009

 

on January 13, 2009, Attorney General Cuomo Announces Historic Nationwide Health Insurance Reform; Ends Practice Of Manipulating Rates To Overcharge Patients By Hundreds Of Millions Of Dollars. The industry wide UCR scam is the biggest consumer fraud of the Century with conflict of interest

 

on January 8, 2009, California Supreme Court ruled that healthcare provide must appeal claim denials on UCR to HMO, health plans, under ERISA for ERISA regulated employer-sponsored  plans. health-care providers may not balance bill HMO patient. HMOs may not simply reimburse healthcare providers at the Medicare rate.

 

More than 80% of non-Medicare claims in USA are ERISA claims, and "Seventy percent of insured working Americans pay higher premiums for insurance plans that allow them to use out-of-network doctors."

 

In the worst economic crisis for 2009, healthcare providers must learn and do ERISA and Medicare claim appeals, or be out of business.

 

NY AG's Settlement Press Release and California Supreme Court Ruling are captioned below with color-coded notation.

 

If you have any questions, please contact Dr. Jin Zhou, the president of the ERISAclaim.com at ERISAclaim@aol.com.

 

 

 


Healthcare Industry Taskforce Banner

 

01/13/2009


Attorney General Cuomo Announces Historic Nationwide Health Insurance Reform; Ends Practice Of Manipulating Rates To Overcharge Patients By Hundreds Of Millions Of Dollars

Industry-Wide Reform of Reimbursement System Will End Conflicts of Interest and Create Fair Rates for Consumers Nationwide

NEW YORK, NY (January 13, 2009) – Attorney General Andrew M. Cuomo today announced historic reform of the nationwide health care reimbursement system that will end conflicts of interest and generate fair reimbursement rates for working families nationwide.  Cuomo has reached an agreement with UnitedHealth Group Inc. (NYSE: UNH) (“United”), the nation’s second largest health insurer, after conducting an industry-wide investigation into a scheme to defraud consumers by manipulating reimbursement rates. 

 

At the center of the scheme is Ingenix, Inc. (“Ingenix”), a wholly-owned subsidiary of United, which is the nation’s largest provider of health care billing information.  Under the agreement with United, the database of billing information operated by Ingenix will close.  United will pay $50 million to a qualified nonprofit organization that will establish a new, independent database to help determine fair out-of-network reimbursement rates for consumers throughout the United States. 

 

For the past ten years, American patients have suffered from unfair reimbursements for critical medical services due to a conflict-ridden system that has been owned, operated, and manipulated by the health insurance industry.  This agreement marks the end of that flawed system,” said Attorney General Cuomo.  “As working families throughout our nation struggle with the burden of health care costs, we will make sure that health insurers keep their promise to pay their fair share.  The industry reforms that we announce today will bring crucial accuracy, transparency, and independence to a broken system.  During these tough economic times, this agreement will keep hundreds of millions of dollars in the pockets of over one hundred million Americans.”

 

In February 2008, the Attorney General announced an industry-wide investigation into allegations that health insurers unfairly saddle consumers with too much of the cost of out-of-network health care.  Seventy percent of insured working Americans pay higher premiums for insurance plans that allow them to use out-of-network doctors In exchange, insurers often promise to cover up to eighty percent of the “usual and customary” rate of the out-of-network expenses, and consumers are responsible for paying the balance of the bill. 

 

United and the largest health insurers in the country rely on the United-owned Ingenix database to determine their “usual and customary” rates.  The Ingenix database uses the insurers’ billing information to calculate “usual and customary” rates for individual claims by assessing how much the same, or similar, medical services would typically cost, generally taking into account the type of service and geographical location.  Under this system, insurers control reimbursement rates that are supposed to fairly reflect the market.  

 

Attorney General Cuomo’s investigation concerned allegations that the Ingenix database intentionally skewed “usual and customary” rates downward through faulty data collection, poor pooling procedures, and the lack of audits.  That means many consumers were forced to pay more than they should have.  The investigation found the rate of underpayment by insurers ranged from ten to twenty-eight percent for various medical services across the state.  The Attorney General found that having a health insurer determine the “usual and customary” rate – a large portion of which the insurer then reimburses – creates an incentive for the insurer to manipulate the rate downward.  The creation of a new database, independently maintained by a nonprofit organization, is designed to remove this conflict of interest.

 

Under Attorney General Cuomo’s agreement with United:

 

  • United will pay $50 million to establish a new, independent database run by a qualified nonprofit organization;
  • The nonprofit will own and operate the new database, and will be the sole arbiter and decision-maker with respect to all data contribution protocols and all other methodologies used in connection with the database;
  • The nonprofit will develop a website where, for the first time, consumers around the country can find out in advance how much they may be reimbursed for common out-of-network medical services in their area;
  • The nonprofit will make rate information from the database available to health insurers;
  • The nonprofit will use the new database to conduct academic research to help improve the health care system;
  • The nonprofit will be selected and announced at a future date.

 

In February 2008, Cuomo also announced that he had issued subpoenas to the nation’s largest health insurance companies that use the Ingenix database, including Aetna (NYSE: AET), CIGNA (NYSE: CI), and WellPoint/Empire BlueCross BlueShield (NYSE: WLP).  The Attorney General’s industry-wide investigation is ongoing.

 

Cuomo continued, “Our agreement with United removes the conflicts of interest that have been inherent in the consumer reimbursement system.  This has been an industry-wide problem, and it demands an industry-wide reform.  We commend United for leading the industry on this issue, and we encourage other insurers to follow suit.”

 

Cuomo was joined by representatives from United and from leading medical and consumer organizations in making today’s announcement at the Saint Vincent Catholic Medical Center in Manhattan.

 

“We are committed to increasing the amount of useful information available in the health care marketplace so that people can make informed decisions, and this agreement is consistent with that approach and philosophy,” said Thomas L. Strickland, Executive Vice President and Chief Legal Officer of UnitedHealth Group.  “We are pleased that a not-for-profit entity will play this important role for the marketplace.”

 

President of the American Medical Association (AMA), Nancy Nielsen, M.D., said, “Today, patients and physicians prevailed over health insurance giant UnitedHealth Group when New York Attorney General Cuomo stopped the insurer from using a rigged Ingenix database that increased insurer profits at the expense of patients and physicians.  The AMA appreciates the leadership of Attorney General Cuomo in initiating his investigation into the Ingenix database, and fully supports the Attorney General’s actions to have a nonprofit entity create a new, reliable database that is fair to patients and physicians.”

 

President of the Medical Society of the State of New York (MSSNY) Michael H. Rosenberg, M.D., said, “We thank Attorney General Cuomo for taking decisive action to finally achieve one of the major goals of a lawsuit that the Medical Society of the State of New York initiated with two other medical societies over eight years ago.  Because of the thorough research and diligent negotiation of Mr. Cuomo and his expert staff, patients and their physicians will no longer be subject to inadequate out-of-network payments determined by the flawed Ingenix database.”

 

Consumers Union Programs Director Chuck Bell said, “Consumers Union greatly appreciates the care that Attorney General Cuomo and his staff have taken in investigating these issues, and creating the careful architecture in this settlement.  This is an extremely sensible, fair solution, which will be of great benefit for consumers nationwide.  We appreciate the fact that United Healthcare has come to the table to resolve these issues in a comprehensive way, and we hope that other insurance companies will quickly get on board, and strongly support this excellent plan to improve transparency for out-of-network charges.”  Consumers Union is the nonprofit publisher of Consumer Reports.

 

Today, Cuomo also issued a report on his investigation, “Health Care Report: The Consumer Reimbursement System is Code Blue.”  The report highlights the conflicts of interest and other defects in the current system and calls for the reforms announced today.  It can be accessed at

 http://www.oag.state.ny.us/bureaus/health_care/HIT/reimbursement_rates.html.  

 

The agreement announced today is the result of an investigation by Deputy Chief of the Health Care Bureau James E. Dering, Senior Trial Counsel Kathryn E. Diaz, and Assistant Attorneys General Brant Campbell and Sandra Rodriguez, under the direction of Linda A. Lacewell, the head of the Attorney General’s Healthcare Industry Taskforce.  The Attorney General expressed his appreciation to Steven E. Fineman, Esq., of Lieff Cabraser Heimann & Bernstein, LLP, for his pro bono services in this matter.

 

For more information, including consumer tips for out-of-network care, or to file a complaint, please visit

 http://www.oag.state.ny.us/bureaus/health_care/HIT/reimbursement_rates.html."

 

**************************

 

2009 UCR in the Media

 

Health insurer settles with NY over bill database
The Associated Press
ALBANY, NY (AP) — Under a settlement with New York, UnitedHealth Group Inc. will overhaul a health insurance industry pricing database to make sure patients ...
UnitedHealth settles NY AG reimbursement probe Reuters
Report: UnitedHealth agrees to settle NY probe Bizjournals.com
Health insurer accused of overcharging millions MSNBC
Connecticut Post - Pioneer Press
all 153 news articles »  UNH

 

Health insurer accused of overcharging millions - Health - TODAYshow.com

 

“This is a huge scam that affected hundreds of millions of Americans [who were] ripped off by their health insurance companies,” says Cuomo. “This was unethical, and it robbed vulnerable patients of insurance reimbursements they deserved.”

 

This is huge. This problem went across the country,” Nancy Nielsen, president of the American Medical Association, told the TODAY show. “It’s industry-wide, throughout insurers. So, it touched every state. Many doctors, many millions of patients, and this has been going on for years.”

 

 

$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

 

Insurer UnitedHealth to pay $350M for settlement
Minneapolis Star Tribune, MN - Jan 15, 2009
Thursday's settlement comes two days after another a $50 million settlement of a probe by New York Attorney General Andrew Cuomo into whether UnitedHealth ...
UnitedHealth Group settles class-action suit over database, Ingenix Chicago Tribune
UnitedHealth agrees to $350 million settlement with AMA ModernHealthcare.com
Insurer UnitedHealth to pay $350M for settlement The Associated Press
Crain's New York Business - MarketWatch (press release)
all 630 news articles »  UNH - OTC:CMTX

Unions Obtain Historic Health Care Settlement for Members and ...
MSNBC - 8 hours ago
On Tuesday, New York Attorney General Andrew Cuomo announced a settlement with United Healthcare in which a new and independent database would be ...
Pomerantz Announces $350 Million Settlement With United Healthcare ... MSNBC

 

 

© JIN ZHOU, President,

ERISAclaim.com

Jan. 16, 2009

 

 

 

Markets News | Reuters

 
 

U.S. doctors urge transparency on insurer payments

Thu Mar 26, 2009 3:57pm EDT
 
* Doctors group says transparency means savings

* AMA urges more openness on out-of-network services

 

"WASHINGTON, March 26 (Reuters) - Requiring health insurers to be more open about how they set reimbursement rates for out-of-network medical services would save everyone money, the top U.S. doctors group told Congress on Thursday.

American Medical Association President Nancy Nielsen said such a move would prevent insurance companies from shortchanging patients and upsetting their relationship with their doctors by underestimating what doctors should be charging for services.

 

"The AMA believes enormous savings would accrue to patients, physicians, health insurers and other third-party payers if there were complete transparency," she told the Senate Commerce, Science and Transportation Committee."

 

 

For more information on how to file appeals for any specific type of denials, please visit DOL website or ERISAclaim.com, you may also contact Dr. Jin Zhou at ERISAclaim.com through ERISAclaim@aol.com.

 

 

ERISA & Claim Denials

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"

 

ERISA & Health Claim
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."

 

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."

 

 

$10,600 ERISA Claim

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.

 

 

   
   Back ] Home ] Next ]

[Copyright © 2001-2009, ERISAclaim.com]    [Privacy and Security Statement]
 

ERISAclaim.com & USHealthcareCrisis.com

1260 Bamberg Court, Hanover Park, Illinois 60133

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

E-mail ERISAclaim@AOL.com