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New Federal Health Claims & Appeals Laws & Regulations

for 193 Million Americans

Effective 09-23-2010

©2010, Jin Zhou, ERISAclaim.com

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ERISA or Non-ERISA Appeals

 

ERISA Appeal or Just Appeal to An ERISA Plan?

Make or Break Your Bank!

 

Maximum Reimbursement through Compliance with ERISA Appeals

 

© JIN ZHOU, President,

ERISAclaim.com

June 23, 2009

 

      It has come to our attention that there has been a lot of confusion among health care reimbursement professionals and industry leaders as to significant difference between a correct, valid and compliant ERISA Appeal and a mere Appeal to ERISA Plans.

 

     A valid and compliant ERISA appeal will ensure maximal benefit reimbursement or recovery for denied benefit claims which a claimant is legally entitled to under the relevant plan provisions under federal law, ERISA claim regulation in accordance with United States Supreme Court unanimously ruling in Aetna v. Davila.

 

      A mere Appeal to an ERISA Plan without specific ERISA compliance is a non-ERISA appeal to an ERISA plan, which may or may not result in optimal reimbursement or recovery for the denied benefits claim from an ERISA plan.

 

      In accordance with DOL ERISA FAQ from U.S. Department of Labor (DOL) website, a mere appeal to an ERISA plan without a valid ERISA assignment of benefits is not a grant of authority to act on a claimant’s behalf in pursuing and appealing a benefit determination under a plan (DOL ERISA FAQ B2), while an ERISA appeal with proper ERISA assignment of benefits will have complete authority and rights under ERISA on a claimant’s behalf to pursue complete document disclosure and maximal benefits under a plan (DOL FAQ B3).

 

DOL ERISA FAQ’s

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

 

DOL ERSA FAQs About The Benefit Claims Procedure Regulation

B-2: Does an assignment of benefits by a claimant to a health care provider constitute the designation of an authorized representative?

 

No. An assignment of benefits by a claimant is generally limited to assignment of the claimant’s right to receive a benefit payment under the terms of the plan. Typically, assignments are not a grant of authority to act on a claimant’s behalf in pursuing and appealing a benefit determination under a plan. In addition, the validity of a designation of an authorized representative will depend on whether the designation has been made in accordance with the procedures established by the plan, if any.

 

B-3: When a claimant has properly authorized a representative to act on his or her behalf, is the plan required to provide benefit determinations and other notifications to the authorized representative, the claimant, or both?

 

Nothing in the regulation precludes a plan from communicating with both the claimant and the claimant’s authorized representative. However, it is the view of the department that, for purposes of the claims procedure rules, when a claimant clearly designates an authorized representative to act and receive notices on his or her behalf with respect to a claim, the plan should, in the absence of a contrary direction from the claimant, direct all information and notifications to which the claimant is otherwise entitled to the representative authorized to act on the claimant’s behalf with respect to that aspect of the claim (e.g., initial determination, request for documents, appeal, etc.). In this regard, it is important that both claimants and plans understand and make clear the extent to which an authorized representative will be acting on behalf of the claimant.

 

      Unfortunately, as a matter of fact and as matter of law, most healthcare reimbursement and/or recovery professionals or consultants are confused on the definition of an ERISA plan and ERISA appeal in believing that ERISA covers only self-insured plans but not fully-insured/funded health plans (“through purchase of insurance”). Nearly 170 million individuals are covered under ERISA in US.

 

      ERISA law governs both self-insured and fully-insured/funded ("through purchase insurance") health plans sponsored by employers in private sector. ERISA statutory definition, 29USC1002, from the U.S. Code Online via GPO Access: (Click here)

 

<http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=browse_usc&docid=Cite:+29USC1002>

 

"From the U.S. Code Online via GPO Access
[www.gpoaccess.gov]
[Laws in effect as of January 3, 2007]
[CITE: 29USC1002]


[Page 312-321]


                             TITLE 29--LABOR
         CHAPTER 18--EMPLOYEE RETIREMENT INCOME SECURITY PROGRAM
            SUBCHAPTER I--PROTECTION OF EMPLOYEE BENEFIT RIGHTS
                      Subtitle A--General Provisions
 

Sec. 1002. Definitions


    For purposes of this subchapter:


    (1) The terms ``employee welfare benefit plan'' and ``welfare plan'' mean any plan, fund, or program which was heretofore or is hereafter established or maintained by an employer or by an employee organization, or by both, to the extent that such plan, fund, or program was  established or is maintained for the purpose of providing for its participants or their beneficiaries, through the purchase of insurance or otherwise, (A) medical, surgical, or hospital care or benefits, or benefits in the event of sickness, accident, disability, death or unemployment, or vacation benefits, apprenticeship or other training programs, or day care centers, scholarship funds, or prepaid legal services, or (B) any benefit described in section 186(c) of this title (other than pensions on retirement or death, and insurance to provide such pensions)......." [[Page 313]]

 

      In accordance with United States Supreme Court unanimously ruling in ERISA judicial appeals, Aetna v. Davila, 06/21/2004, any appeal and lawsuit seeking for benefits payment from an ERISA plan falls completely (100%) within the scope of the ERISA, and all state laws are completely (100%) preempted, invalidated and superseded by ERISA.

      "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. It is so ordered."    Aetna v. Davila, U.S. Supreme Court

 <http://www.law.cornell.edu/supct/html/02-1845.ZS.html>

      ERISA Laws and Facts, Guidance from DOL, if an appeal has complied with all of these ERISA regulation and DOL guidance, it is an ERISA appeal, or otherwise, an appeal is just an appeal to an ERISA plan.

 

 

 

      ERISAclaim.com, (www.ERISAclaim.com), is dedicated to assisting health care providers and employee benefit plans with voluntary compliance to avoid costly and lengthy litigations and to curb health care costs in accordance with U.S. Supreme Court ruling in Aetna v. Davila, and ERISAclaim.com’s advocacy for voluntary compliance was inspired by American Benefits Council’s advocacy for ERISA appeals by health care providers. “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”.

 

      NEWS RELEASE (June 21,2004): Supreme Court Ruling on Health Care Claims Raises Important Policy Issues: American Benefits Council Responds to Critics of Today's Davila, Calad Rulings:

"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.

 

"ERISA is intended to protection patients, not enrich plaintiffs' attorneys. If the objective is to ensure healthy and safe outcomes for patients, then certainly efficient review of claims disputes under ERISA, not inviting litigation, is the way to go," Klein added.”  (Emphasis added) 

 http://www.americanbenefitscouncil.org/newsroom/pr04-32.cfm

      Therefore, as a matter of law and as a matter of fact, a mere appeal to an ERISA plan is not an ERISA appeal to an ERISA plan.

 

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

 

Jin Zhou

President

www.ERISAclaim.com

630-736-2974 (office)

630-808-7237 (mobile)

 

June 23, 2009

 

 

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.

 

 

 

 

Agree to terms and conditions

"Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply."

 

CIGNA - Coverage Positions/Criteria
"The terms of a participant's particular benefit plan document [Group Service Agreement (GSA), Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Positions are based. If these Coverage Positions are inconsistent with the terms of the member's specific benefit plan, then the terms of the member's specific benefit plan always control."

 

UnitedHealthcare Medical Policies

"By clicking "I agree," you agree to be bound by the terms and conditions expressed below, in addition to our Site Use Agreement.

UnitedHealthcare medical policies have been made available to you as a general reference resource. When reading these policies you agree that:

Our Medical Policy is not your patient's Benefit Plan.

Your patient's medical benefits are governed and determined by a benefit document, either a Certificate of Coverage or a Summary Plan Description. You should not rely on the information contained in this Web site section to determine your patient's medical benefits.
 

  1. Federal and state mandates and the patient’s benefit document take precedence over these policies.

  2. The patient’s benefit document lists the specific services that have coverage limits or exclusions.


Our Medical Policy does not address every situation and individuals should always consult their physician before making any decisions on medical care."

 

 

   
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