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U.S. "Healthcare $1
Trillion Crisis"
You Are The Bailout Plan
© JIN ZHOU, President,
ERISAclaim.com
Dec. 09, 2008
"U.S. healthcare crisis is bigger than any
other industries in need of urgent bailout
plan, but healthcare industry will never go to Congress asking for a
$1 trillion bailout plan, as Congress can't afford to bailout
healthcare
$53 trillion crisis.
The U.S. healthcare industry has been doing
its bailout plan in an extremely
unique way: YOU ARE THE BAILOUT
PLAN!
The healthcare Industry employed the same scheme
as other industries have done, healthcare foreclosures and healthcare
repo's:
"OVERPAYMENT
RECOUP = MEDICAL FORECLOSURES AND REPO'S"!
Coupled with no pays, late pays and low pays, the
healthcare industry has been quietly but successfully bailing itself
out from the worst U.S. economic
recession and healthcare recession since WWII.
Healthcare
providers, as the largest share of healthcare bailout,
consumers and employers are all
suffering from this quiet but detrimental
economic medical haemorrhage.
Dr. Jin Zhou, president of ERISAclaim.com in
Illinois, shares his unique insight and
possible practical
solutions for every one.
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Ability to Pay < Liability to Pay =
U.S. $1 trillion Healthcare Bubble
in 2009
$53
trillion in government debts and
liabilities
"The
long-term economic health of the United States is threatened
by $53 trillion in government debts and liabilities that start
to come due in four years when baby boomers begin to retire. (Related
graphic:
U.S. economy threatened by aging of America)
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Insurance Pay Is
Down+Patient Pay Is Down = $7.5T+$14T
Insurance Wanted $$$
Back from You = ERISA
SIU (Private Sector)
Medicare
Wanted $$$ Back from You=MSPRC
&
RAC (Public Sector)
You Are the Healthcare
Bailout Plan=$1 trillion <Overpayment Refund
Healthcare SVU=
Healthcare Special Victim Unit.
Medicare RAC + MSPRC =
$1B (3 states) x 10
states = $10B, 50 states?
ERISA SIU =
Special Investigation Unit, aka, “Overpayment” Dept.
Provider SVU = Special
Victim Unit=No Pay, Low/Late Pay + Payback
Medicare RAC + ERISA
SIU = Provider SVU = $1 trillion Bailout Plan.
How To Survie From $1 Trillion Healthcare
Recession???
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“This
bulletin presents findings of the 2005 National Compensation
Survey (NCS) regarding detailed provisions of healthcare and
retirement plans in private industry conducted by the U.S.
Bureau of Labor Statistics (BLS).”
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•Both the percentage and the
number of people without health insurance increased in 2006.
The percentage without health insurance increased from 15.3
percent in 2005 to 15.8 percent in 2006, and the number of
uninsured increased from 44.8 million to
47.0 million.
•The number of people with health
insurance increased to
249.8 million
in 2006 (up from 249.0 million in 2005). In 2006, the number
of people covered by
private health insurance (201.7 million)
and the number of people covered by
government health insurance (80.3 million)
were not statistically different from 2005.
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•The
percentage of people covered by
employment-based health insurance decreased to
59.7 percent in 2006,
from 60.2 percent in 2005.
•The percentage of people covered
by government health programs decreased to 27.0 percent in
2006,
from 27.3 percent in 2005. The percentage and
the number of people covered by Medicaid were statistically
unchanged at 12.9 percent and 38.3 million, respectively, in
2006.
•Most
people (59.7 percent) were covered by a health insurance plan
related to employment for some or all of 2006,
a proportion that was statistically lower than that of 2005.
The rate of private coverage decreased in 2006 to 67.9
percent, from 68.5 percent in 2005, while the number of people
covered by private insurance was statistically unchanged at
201.7 million in 2006"
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Specific Solutions
from Jin Zhou
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•
ERISA & SPD control coverage and medical necessity, ultimately
control benefits money payment;
•While
MCO contract control provider discount
•MCO
contract is a third-party discount instrument while ERISA &
SPD control benefits entitlement and applicable rights under
the plan.
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Hospital
CEO’s, CFO’s, COO’s, Senior Executive And Management
Teams Must Be Educated On ERISA And Medicare Claim Regulation
And ERISA Impact On Hospitals Bottom Line.
Hospitals
And Healthcare Facilities Must Establish Special Appeals
Department, Beyond And Above Traditional Coding And Billing,
With Highly And Specially Trained Specialists & Experts To
Manage Reimbursement Crisis Through Compliance And Risk
Management –
Special Appeals Department (SAD)
Reimbursement Nowadays = 30% Coding/Billing/MCO
Contracting + 70% Claims Regulations
V:
MANAGED CARE CONTRACTING MUST BE IN COMPLIANCE WITH ERISA,
OR OTHERWISE FINANCIAL SUICIDAL CONTRACTING.
Medicare
Claim Specialists, With Dual
Knowledge & Expertise
V.
•Medicare
Claims Specialist Must Have Dual Knowledge And Expertise,
Similar To The Requirements For Medicare Second Level Appeal
(Reconsideration) Panel Members (QIC’s)
•Dual
Knowledge & Expertise = Coding & Billing + Medicare Claim
Regulation + Sufficient Medicolegal + Appeal Strategy
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| You are the
bailout plan by default, regardless if you see it or like it.
Billing and coding have nothing to do with
this crisis turnaround
Documentation quality has nothing to do
with this crisis turnaround
Fraud and abuse Prevention has nothing to
do with this crisis turnaround
Managed care contracting has nothing to do
with this crisis turnaround
It is about jungle survival when everyone
is at bankruptcy doorsteps when we are all in a nightmare of at
least $1 trillion short.
ERISA and Medicare compliant strategies
and appeals are the only way to survive in this economic crisis. |
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| Dr. Jin Zhou
will show you how to survive from this healthcare recession with
$1 trillion healthcare bubble.
Jin Zhou
President
www.ERISAclaim.com
630-736-2974 (Office)
630-808-7237 (Mobile) |
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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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View
CMS Chart
Series
CMS Facts & Figures
CMS offers various Chart Series with recent data on
spending, operations, and quality of care in CMS programs. The
Chart Series also offer some information on the nation´s
health care system, and CMS internal operations.
Each of the sections covers a different topic, and is
available to view or download as a PowerPoint presentation (.ppt
file, recommended) or in Adobe Acrobat (.pdf) format.
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QIC News
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CERT
Reports
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AHCPR
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New Chiro Demo
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Expansion of Coverage of Chiropractic Services Demonstration
(CMS)
April 06, 2005 -
MEDICARE IMPLEMENTS DEMONSTRATION TO EXPAND COVERAGE OF
CHIROPRACTIC SERVICES
MEDICARE CHIROPRACTIC SERVICES
DEMONSTRATION
FINAL DESIGN REPORT,
Click here. (pdf. 532kb)
April 27, 2005
-
Federal Register Notice (.pdf 57 kb)
-
Press Release (.pdf 58 kb)
-
Chiropractor Medlearn Matters Article
-
Laboratory Medlearn Matters Article
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Radiology Medlearn Matters Article
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Chiropractor Power Point Presentation (.pdf 177 kb)
- Beneficiary Fact Sheets
- Demonstration Geographic Areas
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Diagnosis and Procedure Codes (.pdf 135 kb)
-
Frequently Asked Questions and Answers
(pdf. 18kb)
05/06/2005
INSTRUCTIONS RELEASED -- MID-QUARTER
Transmittal 34 ... This instruction affects Comprehensive
Outpatient Rehabilitation Facilities, Outpatient
Physical
Therapy, Skilled Nursing Facilities, Physicians and
Non-Physician Practitioners.
View the complete text of Transmittal 34
(PDF - 366 KB)
MM3648 (Revisions to the Medicare Benefit Policy Manual
(Pub 100-02), Chapter 15, Sections 220 and 230 Regarding Therapy
Services)
SE0533 (Further Clarification of CR3648, Which Revised
the Medicare Benefit Policy Manual (Pub 100-02), Chapter 15,
Regarding Therapy Services)
National Correct Coding Policy Manual for Part B Medicare
Carriers -- Version 10.3
"O. Chiropractic Manipulative Treatment"
[page 14 of 18]
United States of America v. Thomas Bruce Vest,
also known as T. Bruce Vest, doing business as Doctors Clinic
"Second, the Government presented 36 patients
who testified that during their visits to the Doctors Clinic,
they did not report many of the symptoms and past conditions
that Vest recorded on their medical records."
Fraud And Abuse
Fighting Fraud & Abuse
MM3449
Revised Requirements for Chiropractic Billing of
Active/Corrective Treatment and Maintenance Therapy, Full
Replacement of CR 3063
Revised: 11/19/2004
CR3449 (10/08/2004)
CMS
Documentation Guidelines — Evaluation and Management
Services
R125PI
CR4022
"Medical
Review Additional Documentation Requests"
R123PI - CR3703
9/23/2005
"Chapter
3, MMA Section 935
I. SUMMARY OF CHANGES: This change implements
portions of Section 935 of the MMA (entitled
Recovery of Overpayments). Specifically, this CR
explains to contractors their right to
request documentation for a limited sample of submitted
claims, after overpayments have been identified,"
CMS 2004 Transmittals 90-CR3569:
Prepayment Review of Claims for MR Purposes
(pdf)
"Contractors shall not initiate non-random prepayment
medical review of a provider or supplier based on the initial
identification by that provider or supplier of an improper
billing practice unless there is a likelihood of a sustained
or high level of payment error."
CMS 2005
Transmittal 120
--
CHANGE REQUEST 3880
"Correction to Change Request (CR) 3222:
Local Medical Review Policy/ Local Coverage Determination
Medicare Summary Notice (MSN) Message Revision"
"E. Distinguishing Between
Benefit Category, Statutory Exclusion and Reasonable and
Necessary Denials"
R13SOM: Revisions to
Chapter 2, "The Certification Process," Appendix E--
"Providers of Outpatient Physical Therapy or Outpatient Speech
Language Pathology (OPT/OSP) Services," and Appendix K--
"Comprehensive Outpatient Rehabilitation Facilities"
Medicare Program Integrity Manual
Chapter 3: Verifying Potential Errors and Taking
Corrective Actions (pdf)
(Zipped Word File)
Medical Review Strategy
"In addition to carry-over of several of the
FY 2004 focuses, the new FY 2005 focus areas will be:
 | Chiropractic services
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| Level of consultations
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| Follow-up consultations |
Transmittal 34
General Coverage of Physician Services***NCP
PHYS-001
Physician Visits, Documentation and
Interpretation of Test Results***NCP
PHYS-002
Incident To a Physician's Professional Service
in the Office or Clinic***NCP
PHYS-004
Outpatient Physical
Therapy, Occupational Therapy and Speech-Language
Pathology
PHYSMED-001
Coding Guidelines:
"...7. *The date the patient was last seen and the
UPIN of the
attending physician must be listed in
Item 19 on the CMS-1500 form or the electronic
equivalent."
Physical Medicine and Rehabilitation Procedures
and Modalities
PHYSMED-009
Neuromuscular Electrical Stimulation (NMES)
PHYSMED-011
Illinois
WPS Medicare Part B - Provider Education - Claim Information
Seminar Schedule
" WPS
is frequently asked if we offer Continuing Education Units (CEUs)
for our programs. We are happy to announce that......"
Seminar Materials
CMS (HCFA) 1500 Claim Form Instructions
(pdf - 72
pages; 695KB)
Timely Filing of Claims
Unprocessable Claim Guidelines
How to Appeal a Claim Determination
Chiropractic Care Educational Guidebook
(pdf - 95
pages; 476KB)
- Jan. 2005
WPS Medicare Part B - Chiropractic
FAQs
WPS Medicare Part B - 2005 Medicare Payment Information
Available from CD-Rom
Medicare Part B WPS Search on "chiropractic care"
Teleconferences
WPS Communiqué
Virginia TrailBlazer Part BHome
Page
1500 Claim Form/Unprocessable Claim Form Instructions
Top 10 Billing Errors
General Principles of Documenting Patient's Medical Records
Provider Outreach and Education (Educational issues)
Audio Training
Chiropractic Services
CMS 1500 Claim Form Instructions
Part B Problem Solving Guide
 or the
TrailBlazer Medicare Part B Mid - Atlantic Important
Contacts .
Iowa
Noridian Medicare: Provider Homepage
Noridian Medicare: Provider: Publications: Medicare B: Medical
Policies
Chiropractic Services Policy
Chiropractic BBM July 2003
Chiropractic Care
Documentation
Diagnosis Criteria
x-ray
Advanced Beneficiary Notice
Questions and Answers
Chiropractic Demonstration Project
Appeals
Recoupment
EDI
Education
Telephone Appeals Changing Hours
5/11/2005
Medicare Part B Appeal
Documentation
Fraud and Abuse
Medicare Part B: Medicare Chiropractic Billing
Medicare Part B Workshop
Medicare B News Bulletins and LMRPs-LCDs(1994 to Current)
NM
Welcome To Arkansas Medicare Services
Fee Schedules
How to Complete the CMS-1500 Form
Helpful Hints for Filing Claims
Maine
National Heritage Insurance Company
National Heritage Insurance Company is the
Medicare Part B contractor for California,
Maine, Massachusetts, New
Hampshire, and Vermont, serving 5.5 million beneficiaries and
178,000 healthcare providers. |
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Physical Therapy Documention Books
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CMS Contractors
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