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Moukawsher & Walsh, LLC
Pension and Employee Benefit Law



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
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US Supreme Court Visits

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,

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



(Links to DOL) ©2010, Jin Zhou,

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 - Free Webinars - New Federal Claims & Appeals Regulations, Effective Sept. 23, 2010, for 193 Million Americans Seminars - 2010 Two-day Basic ERISA Appeal Seminars - Denials and Overpayment Appeals - 2010 PPACA & ERISA Claim Specialist Certification Programs in Chicago, Illinois  Create An Appeal Department for Your Hospital or Practice (In-house, onsite ERISA Claim Specialist Certification Programs)


Health Reform for Out-Of-Network Providers:

Receiving Insurance Checks Directly from an ERISA Plan?


© JIN ZHOU, President,

April 5, 2010


Health Reform for Out-Of-Network Providers: Receiving Insurance Checks Directly? – Free Webinars on Why and How  04/05/2010, Hanover Park, IL Expanded Its Free Webinars to Cover New Obama Health Reform and Reimbursement Laws for Out-Of-Network Non-Participating Provider's Rights to Receive Insurance Reimbursement Checks Directly with Valid Assignment and Nondiscrimination Protections for Nonparticipation. New Obama Health Reform Law Mandates Every Group and Individual Health Plan to Accept Patient Assignment to Send Reimbursement Checks Directly to Providers Regardless of Participation, by Incorporating Existing Federal Law, ERISA, and in Consistent with Recent U.S. Supreme Court Orders.'s ERISA Appeal CD Book & Systems and Seminars Provide Complete Sample Forms and Letters to Assistant Out-Of-Network Providers to Exercise ERISA Rights, Including Right to Receive Reimbursement Checks Directly From Payors.

Hanover Park, IL (PRWEB) April 5, 2010 – announced special coverage of its free webinars to discuss recent Obama health reform law for out-of-network non-participating provider's rights to directly receive insurance reimbursement checks with valid ERISA assignment of benefits and non-discrimination protections regardless of non-participation. Patient Protection and Affordable Care Act, PPACA, went into effect upon the enactment of the act on March 23, 2010. PPACA incorporates or adopts existing federal law, ERISA, for all group and individual health plans to mandate unconditional acceptance of valid patient assignments for disbursement of reimbursement checks directly to the designated health care providers regardless of their network participation. A recent United States Supreme Court ruling ordered ERISA plan administrators to disburse benefits solely based on plan document and valid assignment instead of any external documents. About 70% of insured working Americans paid higher premiums for out-of-network coverage and rights to see nonparticipating providers on UCR fee schedules. has been offering free webinars on new health reform laws for doctors and hospitals since the House of Representatives passed its version of health care reform bills in last November. Due to the overwhelming reception from the webinar attendees and increasing demand from non--participating providers for such topics, as result of recent announcement from many major insurance companies that no insurance reimbursement checks will be sent to out-of-network providers.


The Webinars will cover very specific provisions, §2719 and §2706, of new healthcare reform law, Patient Protection and Affordable Care Act, PPACA, in reference to mandatory compliance with the established ERISA claim regulation in its entirety, ERISA §2560.503-1 for every group health plan an individual plan. ERISA §2560.503-1 (b)(4) prohibits any anti-assignment practice and discrimination by any group health plan in refusing to disburse benefits checks with valid patient assignments. Department of Labor, DOL, issued enforcement guidelines, DOL ERISA FAQ, B3, in explaining plan administrator’s fiduciary duties in compliance with ERISA assignment requirement. United States Supreme Court ruled on January 26, 2009 in Kennedy v. Plan Administrator for DuPont that ERISA plan administrators must make benefits determination and benefits disbursement decisions solely based on plan documents and valid participant assignment.


According to Dr. Jin Zhou, president of, a national ERISA expert, and reimbursement compliance consultant, it is increasingly popular from industry existing practice that health care providers historically ignored these protections from federal law, ERISA, in failing to secure valid ERISA Legal Assignment for Benefits from their patients, therefore insurance companies and health plans will have no obligations to any health care providers in absence of valid ERISA assignments, in accordance with DOL claim guidelines, ERISA FAQ, B2. On the other hand, if with a valid ERISA assignment, and an insurance company or health plan must send reimbursement checks directly to healthcare providers as a designated and authorized representative, regardless of network participation, pursuant to DOL ERISA FAQ B3. Dr. Zhou also explained ERISA claim regulation has outlawed industry anti-assignment practice since January 2003.


Patient Protection and Affordable Care Act, PPACA §2706, went into effect upon its enactment of the act, on March 23, 2010, after President Barack Obama signed PPACA into law.


Patient Protection and Affordable Care Act, PPACA, specifically prohibits any discrimination against any health care providers regardless of network participation:




`(a) Providers- A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider's license or certification under applicable State law."




United States Supreme Court ordered in Kennedy v. Plan Administrator for Dupont, on January 26, 2009, that the plan administrator must pay ERISA benefits to the party in conformity of the plan document, instead of PPO or TPA guidelines. ERISA provides no excuses or exceptions to the plan administrator’s duty to act in accordance with plan document and participant designation for whom the benefit checks should be sent to. The plan administrators failure and refusal to send benefit checks directly to the authorized and designated representative is judged by the plan documents, including participant designation and legal assignment of benefits. 29 U. S. C. §1132(a)(1)(B), a straight forward rule that lets employers “ ‘establish a uniform administrative scheme, [with] a set of standard procedures to guide processing of claims and disbursement of benefits to the designated and authorized representative. By giving a plan participant, our patient as captioned above, a clear set of instructions for making his own instructions clear, ERISA forecloses the plan and your TPA from any justification for enquiries into expressions of intent, in favor of the virtues of adhering to an uncomplicated rule, ERISA claim regulations, rather than your TPA’s personal opinions, PPO private contract or undisclosed protocols. Less certain rules, such as your current noncompliant policies of anti-assignment, could force plan administrators to examine numerous external documents, such as TPA or PPO rules, purporting to be waivers and draw them into litigations inevitably forthcoming over your current practice of anti-assignment and refusal to comply with plan participant unambiguous fiduciary instructions to send reimbursement checks directly to health care providers clearly designated and authorized by such plan participant or beneficiary.







No. 07–636. Argued October 7, 2008—Decided January 26, 2009

""2. Although Liv’s waiver was not nullified by §1056’s express terms, the plan administrator did its ERISA duty by paying the SIP benefits to Liv in conformity with the plan documents. ERISA provides no exception to the plan administrator’s duty to act in accordance with plan documents. Thus, the Estate’s claim stands or falls by “the terms of the plan,” 29 U. S. C. §1132(a)(1)(B), a straight for-ward rule that lets employers “ ‘establish a uniform administrative scheme, [with] a set of standard procedures to guide processing of claims and disbursement of benefits,’ ” Egelhoff v. Egelhoff, 532 U. S. 141, 148. By giving a plan participant a clear set of instructions for making his own instructions clear, ERISA forecloses any justification for enquiries into expressions of intent, in favor of the virtues of adhering to an uncomplicated rule. Less certain rules could force plan administrators to examine numerous external documents purporting to be waivers and draw them into litigation like this over those waivers’ meaning and enforceability......."(Emphasis added)


"disbursement of benefits" = whom, how and where to send benefits checks to

Patient Protection and Affordable Care Act, PPACA §2719, requires every group health plan to comply with the established ERISA appeal process, 29 CFR, §2560.503-1:



`(a) Internal Claims Appeals-

`(1) IN GENERAL- A group health plan and a health insurance issuer offering group or individual health insurance coverage shall implement an effective appeals process for appeals of coverage determinations and claims, under which the plan or issuer shall, at a minimum—


`(A) have in effect an internal claims appeal process;
`(B) provide notice to enrollees, in a culturally and linguistically appropriate manner, of available internal and external appeals processes, and the availability of any applicable office of health insurance consumer assistance or ombudsman established under section 2793 to assist such enrollees with the appeals processes; and
`(C) allow an enrollee to review their file, to present evidence and testimony as part of the appeals process, and to receive continued coverage pending the outcome of the appeals process.

`(2) ESTABLISHED PROCESSES- To comply with paragraph (1)—

`(A) a group health plan and a health insurance issuer offering group health coverage shall provide an internal claims and appeals process that initially incorporates the claims and appeals procedures (including urgent claims) set forth at section 2560.503-1 of title 29, Code of Federal Regulations, as published on November 21, 2000 (65 Fed. Reg. 70256), and shall update such process in accordance with any standards established by the Secretary of Labor for such plans and issuers; and
`(B) a health insurance issuer offering individual health coverage, and any other issuer not subject to subparagraph (A), shall provide an internal claims and appeals process that initially incorporates the claims and appeals procedures set forth under applicable law (as in existence on the date of enactment of this section), and shall update such process in accordance with any standards established by the Secretary of Health and Human Services for such issuers.” (Emphasis added)


ERISA claim regulation has outlawed since Jan. 01, 2003, the traditional anti-assignment practice by the industry for 28 years and mandates the plan to send checks and all information and documents to the provider who is properly authorized representative on behalf of the patient regardless of network participation:





§ 2560.503–1 Claims procedure.

"(b) Obligation to establish and maintain reasonable claims procedures.


Every employee benefit plan shall establish and maintain reasonable procedures governing the filing of benefit claims, notification of benefit determinations, and appeal of adverse benefit determinations (hereinafter collectively referred to as claims procedures). The claims procedures for a plan will be deemed to be reasonable only if



(4) The claims procedures do not preclude an authorized representative of a claimant from acting on behalf of such claimant in pursuing a benefit claim or appeal of an adverse benefit determination. Nevertheless, a plan may establish reasonable procedures for determining whether an individual has been authorized to act on behalf of a claimant, provided that, in the case of a claim involving urgent care, within the meaning of paragraph (m)(1) of this section, a health care professional, within the meaning of paragraph (m)(7) of this section, with knowledge of a claimant’s medical condition shall be permitted to act as the authorized representative of the claimant; ...."

DOL ERISA FAQ's B3 clarifies §2560.503-1 (b)(4) to mean that an ERISA plan should send reimbursement checks directly the out-of-network providers who is properly authorized by a patient regardless of network participation, unless a patient instruct the plan not to. The decision to send the check to which provider is from the patient, not the plan or PPO opertors.


DOL 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."

As President Barack Obama explained the new PPACA and ERISA Appeals on Jan 09, 2010 in his weekly address:


”And there will be a new, independent appeals process for anyone who feels they were unfairly denied a claim by their insurance company.


In short, once I sign health insurance reform into law, doctors and patients will have more control over their health care decisions, and insurance company bureaucrats will have less.  All told, these changes represent the most sweeping reforms and toughest restrictions on insurance companies that this country has ever known.”




According to New York Attorney General Andrew M. Cuomo on January 13, 2009, about 70% of insured working Americans paid higher premiums for out-of-network coverage and providers. It is a matter of national economic social security for working American families if they will get the benefit as promised, said Dr. Zhou.


“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.”




New free webinars are a part of continued efforts from on a weekly and monthly basis to help all involved with very specific and accurate statutory provision reviews and discussions on all new Obama health law mandates for claim appeals. The time for each free webinar is 60 minutes, from 11 AM to 12 PM, or 1 PM to 2 PM, Central Standard Time. Registration is free for all. The Webinar Handout is also available and free to download at:


In the past 10 years, has been the only ERISA Specialized Company offering the most practical and comprehensive ERISA education, consulting and publishing services for healthcare providers in administrative ERISA appeals for real problem oriented denials under the most mysterious 35-year-old federal law, ERISA. Dr. Jin Zhou, president has been regarded as the Godfather of ERISA claims for healthcare providers by some in Professional billing and coding industry.'s ERISA Appeal CD Book & Systems and Seminars Provide Complete Sample Forms and Letters to Assistant Out-Of-Network Providers to Exercise ERISA Rights, Including Right to Receive Reimbursement Checks Directly From Payors. 


For more information or to arrange an interview, please contact Dr. Jin Zhou, president of at 630-808-723 and or visit: <>




Jin Zhou, President

Tel: 630-808-7237 (Mobile)

Tel: 630-736-2974 (Office)

Fax: 630-736-1439




Related Links: 50% Savings - Healthcare Crisis Turnaround for Employers, Insurers & TPA's - A $1.0 Trillion Nuclear Solution to U.S. Health-care Crisis & $44 Trillion Budget Deficits


American Benefits Council: News Room - Supreme Court Ruling on Health Care Claims Raises Important Policy Issues: American Benefits Council. June 21, 2004

"Sadly and predictably trial attorneys and their allies are already calling on Congress to unravel today’s decision by the Supreme Court, but they should first ask why the two physicians in these cases did not act swiftly to help make sure their patients got the care they were seeking. In neither case did the patient or their physician seek a further review of the health plan’s initial coverage decision, despite being specifically informed of their right to such a review under federal law." Klein said."


"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."


# # #

The American Benefits Council is the national trade association for companies concerned about federal legislation and regulations affecting all aspects of the employee benefits system. 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."


Lexology - Notes on the National Summit on Health Care Fraud

Reed Smith LLP, USA


February 1 2010

"Last week, in my capacity as president of the American Health Lawyers Association, I attended the first National Summit on Health Care Fraud, a joint undertaking by the U.S. Department of Health and Human Services and the U.S. Department of Justice. The conference brought together private sector leaders, law enforcement personnel, and health care experts as part of the Obama Administration’s coordinated effort to fight health care fraud. This was the first national gathering on health care fraud between law enforcement and the private and public sectors."  

STOP Medicare Fraud - U.S. Department of Health & Human Services and U.S. Department of Justice (

"National Summit on Health Care Fraud

U.S. Department of Health and Human Services Secretary Kathleen Sebelius and Attorney General Eric Holder convened a “National Summit on Health Care Fraud” on Thursday January 28, to bring together leaders from the public and private sectors to identify and discuss innovative ways to eliminate fraud, waste and abuse in the U.S. health care system. The National Summit is the latest initiative of the Health Care Fraud Prevention & Enforcement Action Team (HEAT)."



Related Press Release links:


The New 2010 Obama Healthcare Reimbursement Law Webinars Announced As ERISA Appeals Procedures Now Mandatory for All Group Health Plans and Healthcare Providers  01-04-2010, Hanover Park, IL


Free Overpayment Webinar Announced For Self-insured Health Plans To Get Immediate Relief from New $1 Trillion Overpayment Recoupment Embezzlement Market 11-23-2009, Hanover Park, IL


New Healthcare Overpayment Recoupment Embezzlement Recovery Service Announced In Wake Of Launch of New Federal Task Force To Combat Healthcare Fraud Crisis 11-19-2009, Hanover Park, IL


The New Healthcare Reform Bill Passed by The Congress Prompted The New Claim Specialist Certification Class from 11-9-2009, Hanover Park, IL Announced The Nation's First Embezzlement Recovery Services for Large ERISA Health Plans from the $6 Trillion Healthcare Denial Management Market 10-23-2009, Hanover Park, IL Announced Free ERISA Webinar for Healthcare Overpayment Dispute and Claim Denials in Response to Increasing High Demand from the $6 Trillion Healthcare Denial Management Market  10-19-2009, Hanover Park, IL Announced the Expansion of Its ERISA Litigation Support For the Healthcare Claims In Response to Increasing High Demand from the $6 Trillion Healthcare Denial Management Market. 10-19-2009, Hanover Park, IL 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 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





Interactive Side-By-Side Health Reform Comparison Tool of Major Proposals (Kaiser Family Foundation)

Excerpt: "The Foundation has updated its health reform resources to reflect provisions of the Affordable Health Care for America Act (HR 3962) as passed on Saturday by the U.S. House of Representatives."

Information updated 03/26/2010



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."




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

        Selected links:

Sec. 1002.

Sec. 1003.

Sec. 1022.
Summary plan description

Sec. 1027.

Retention of records
Sec. 1104.
Fiduciary duties


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:


        Selected links:

2520.102-3 Contents of summary plan description.

Claims procedure.



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