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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>
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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.
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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. |
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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]]
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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 |
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ERISA &
Claim Denials
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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" |
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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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$10,600 ERISA Claim
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$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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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.
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Federal and state mandates and the patient’s
benefit document take precedence over these policies.
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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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