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Links to Plan Bronchures for 2009

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New Federal Health Claims & Appeals Laws & Regulations

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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

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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

 

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ERISAclaim.com:  Create An Appeal Department for Your Hospital or Practice (In-house, onsite ERISA Claim Specialist Certification Programs)

 

ERISAclaim.com - 2010 Claim Denial & Overpayment Dispute Two-day ERISA Appeal Seminars,

 

ERISAclaim.com - 2010 ERISA Claim Specialist Certification Programs in Chicago, Illinois

 

New ERISA Appeal Book with 2010 Major Updates  $450  & $150 (Updates only with previous purchase)

 

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ERISAclaim.com - Free ERISA Webinar, The Beginning for $6 Trillion Healthcare Denial Management Market

 

Overpayment & SIU in 2009

$1 Trillion Healthcare Bailout & Foreclosures

© JIN ZHOU, President,

ERISAclaim.com

April 18, 2009

We  provide SAA (Specialty Appeal Assistance) to healthcare providers when they  first received SIU letters and  even after their lawyers failed to reach "an amicable settlement".

Email: ERISAclaim@aol.com;

Phone: 630-736-2974 (Office), 630-828-7237 (Mobile)

 

Related Links:

 

ERISAclaim.com - "Overpayment" Refund Request Response & Appeals

ERISAclaim.com - The Death of Managed Care & Health Insurance Industry UCR Fraud

ERISAclaim.com - U.S. "Healthcare $1 Trillion Crisis", You Are The Bailout Plan

ERISAclaim.com - New Medicare Overpayment Appeal - "Dr. Joe (Zhou), the RAC Invalidator"

ERISAclaim.com - ERISA or PPO? Managed Care Slavery or ERISA Superhero

ERISAclaim.com - ERISA & Your Money, Compliant Reimbursement Beyond and Above Coding/Billing + MCO Contracting

ERISAclaim.com - ERISA & Your Insanity - Healthcare Claim Reimbursement Rx from Einstein & Supreme Court

ERISAclaim.com - 950,000 MD's Settled With Aetna & Cigna on ERISA

 

 

Pomerantz Files Class Action Against Blue Cross Blue Shield Association ("BCBSA") and Related BCBSA Entities

Reuters, Thu Sep 10, 2009 6:11pm EDT

 

CHICAGO--(Business Wire)--

"Pomerantz Haudek Grossman & Gross LLP today announced that it and co-counsel Buttaci & Leardi, LLC filed a class action lawsuit against the Blue Cross Blue Shield Association ("BCBSA") and 22 leading BCBS insurers across the country on behalf of a putative nationwide class of health care providers, as well as the Pennsylvania Chiropractic Association ("PCA"), the New York Chiropractic Council (the "Council"), and the Association of New Jersey Chiropractors ("ANJC"). The suit challenges the Defendants` abusive practices in using post-payment audits and reviews, and improper repayment demands, to pressure providers to repay substantial sums that have previously properly been paid as health insurance benefits for services provided to BCBS subscribers.

 

......In making the appointment, the Court stressed the significant role Pomerantz had played in a $249 million settlement of its UCR class action against Health Net, stating that the Court had "similarly appointed Pomerantz to be Plaintiffs` spokesman to the Court in the Health Net litigation because the Court found D. Brian Hufford, Esq. to be the attorney most capable of presenting Plaintiffs` position in a clear and concise manner." In re Aetna UCR Litig., 2009 Dist. LEXIS 66853, *8 n.4 (D.N.J. July 31, 2009)."

For a copy of the BCBSA Complaint, click here


Pomerantz Files Class Action Against Blue Cross Blue Shield Association

 

Sept. 10, 2009

"Pomerantz filed a class action lawsuit against the Blue Cross Blue Shield Association ("BCBSA") and 22 leading BCBS insurers across the country on behalf of a putative nationwide class of health care providers, as well as the Pennsylvania Chiropractic Association ("PCA"), the New York Chiropractic Council (the "Council"), and the Association of New Jersey Chiropractors ("ANJC"). The suit challenges the Defendants' abusive practices in using post-payment audits and reviews, and improper repayment demands, to pressure providers to repay substantial sums that have previously properly been paid as health insurance benefits for services provided to BCBS subscribers."

For a copy of the BCBSA Complaint, click here

 

 

 

Pomerantz Files Class Action Against Aetna (News from Pomerantz)

 

For a Copy of the Official Complaint, click here

 

Pomerantz Files Class Action Suit Against Aetna On Behalf of Healthcare Providers to Challenge Abusive Post-Payment Audit Practices (GlobeNewsWire, press release)

 

"NEWARK, N.J., July 29, 2009 (GLOBE NEWSWIRE) -- Pomerantz Haudek Grossman & Gross LLP today announced that it and co-counsel Buttaci & Leardi, LLC, have filed a class action lawsuit against Aetna, Inc., and its various health insurance subsidiaries on behalf of a putative nationwide class of health care providers, the Association of New Jersey Chiropractors ("ANJC") and the New York Chiropractic Council ("NYCC"). The suit challenges Aetna's abusive practices in using post-payment audits, with false allegations of fraud, to pressure providers to repay substantial sums that have previously properly been paid for providing services to Aetna subscribers.

The action alleges that Aetna's post-payment audit process violates the Employee Retirement Income Security Act of 1974 ("ERISA"), in that its repayment demands are retroactive determinations that particular services are not covered under the terms of Aetna's health care plans, but without any of the appeal or other protections otherwise available under ERISA for both self-funded and fully insured health care plans offered through private employers. The complaint further alleges that both the post-payment audit process and the pre-payment claim review process employed by Aetna to strong-arm chiropractors into unfavorable settlements violate the Racketeer Influenced and Corrupt Organizations Act ("RICO"). In addition to challenging the process by which Aetna pursues and applies its audits, the complaint also challenges numerous clinical policy bulletins of Aetna, which are used to deny services retroactively without adequate basis or clinical support."

ERISAclaim.com - "Overpayment" Refund Request Response & Appeals

BCBSA News, June 30, 2009

Blue Cross And Blue Shield Companies' Anti-Fraud Efforts Recover $350 Million In 2008

"WASHINGTON – Blue Cross and Blue Shield companies' anti-fraud investigations resulted in overall savings and recoveries of nearly $350 million in 2008, an increase of 43 percent from 2007, according to data released today by the Blue Cross and Blue Shield Association (BCBSA) National Anti-fraud Department (NAFD).  From 2007 to 2008, the number of cases opened increased nearly 34 percent, and the closed cases increased about 43 percent."

AMNews: July 6, 2009. Tennessee Medical Assn. sues collections firm
Health Research Insights has contacted physicians in several states this year trying to collect alleged overpayments.

 

For A Copy of TMA v. HRI Lawsuit, click here
 

AMNews: May 18, 2009. State medical societies strategize against collector
Legal action is one option against Health Research Insights.
 

AMNews: May 11, 2009. Company stops tapping physicians for 'overpayments'
Doctors protested self-insured Georgia-Pacific's attempt to collect refunds of suspected claims upcoding.
 

AMNews: April 13, 2009. Self-insured companies going after doctors to recover 'overpaid' claims
There is no clear time limit on how far back ERISA-protected companies can go to recoup money. One company is turning that into a business.

 

Overpayment Demand Letter from HRI:

"Dear Health Care Professional,

 

......You must take action as outlined in items (1) or (2) above, in order to ensure compliance with the Employee Retirement Income Security Act of 1974 (ERISA). ERISA is the federal law that, among other things, governs health benefit plans in private industry. Investigation of potential ERISA violations is given to the United States Secretary of Labor pursuant to sections 504 and 506 as amended by the Comprehensive Crime Control Act of 1984 and enforced by the US Department of Labor.

 

In the event HRI is not contacted by you or your designee, a Complaint may be filed with the Employee Benefits Security Administration (EBSA). You may view additional information at (www.dol.gov/ebsa)."

Physicians Strike Back At Employers' Collection Firms ( BNET Healthcare Blog | BNET)

"In the most recent clash, the Tennessee Medical Association has sued Health Research Insights (HRI), a Franklin, TN-based firm that has sent collection letters to physicians in Georgia, Kentucky, Tennessee and Texas. Other defendants in the suit include the Metropolitan Government of Nashville and Davidson County, TN, and Nashville’s Board of Education, which runs a self-insured plan for school employees. Blue Cross and Blue Shield of Tennessee, the plan’s administrator, is also named in the suit, although the insurer disavows any relationship with the collection firm.

 

The suit, which alleges fraud, says that HRI keeps 40 percent of whatever it collects. The TMA wants a court to enjoin HRI from making any further efforts to collect from physicians. An earlier protest by the Georgia Medical Society against HRI’s work on behalf of Georgia Pacific led to a suspension of those activities."

Employment-Based Health Coverage and Health Reform: Selected Legal Considerations (PDF) (U.S. Congressional Research Service)

"It is estimated that nearly 170 million individuals have employer-based health coverage. As part of a comprehensive health care reform effort, there has been support (including from the Obama Administration) in enacting comprehensive health insurance reform that retains the employerbased system. This report presents selected legal considerations inherent in amending two of the primary federal laws governing employer-sponsored health care: the Employee Retirement Income Security Act (ERISA) and the Internal Revenue Code (IRC)."

ERISAclaim.com - "Overpayment" Refund Request Response & Appeals

 

 

Hospitals and health-care providers  have been in $1 trillion foreclosure in 2009 as healthcare industry bailout by SIU ( Special Investigation Unit) from every healthcare plan payors, managed-care network operators and even Medicare (RAC, Recovery Auditing Contractor). This kind of sophisticated healthcare provider foreclosure has been carried out, politically correctly, as anti-fraud or abuse prevention program, while more than 95% of $1 trillion overpayment "takeback" or recoupment are truly retrospective benefits denials.

 

Any non-compliant overpayment refund practice by SIU's by violating and disregarding of ERISA claim regulations and individual plan provisions could or might be the worst fraud for the century and  will severely destroy U.S. health care infrastructure, and defraud millions of consumers for billions of dollars. Only ERISA and Medicare Compliant overpayment refund recoupment by the payers and appeals by the providers can cut the cost, eliminate fraud and abuse and protect patients and U.S. healthcare system.

 

Hospitals and health-care providers have been childishly entertained and foreclosed by the SIU or commercial debt collectors for millions of dollars while being clueless and confidently defending "fraud investigation" and being denied for more and more new claims due to pending "fraud investigation" settlement.

 

Except for less than 5% of the alleged overpayment being pure fraud,  more than 90% of non-Medicare "overpayment" claims are ERISA claims being retrospectively denied, as  revised initial benefits determination as a result of post payment SIU reviews, and this type of dispute must be handled  under ERISA claim regulation with respect to specific appeal process under each individual health plan and in accordance with each individual plan documents, Summary Plan Description (SPD), rather than state insurance laws and  private managed-care contracts, similar to Medicare overpayment  recovery process. Medicare's RAC (Recovery Auditing Contractor) overpayment and appeal process are completely governed and regulated by Medicare claim regulations.

 

If you are currently facing any SIU ( Special Investigation Unit) demand for overpayment refund for a significant amount of dollars, and being denied for new claims in  significant amount of dollars, we at ERISAclaim.com provide SAA ( Special Appeal Assistance) for healthcare providers to defend through complaint appeals against any overpayment harassment and to timely secure applicable payment for your current claims.

 

We  provide SAA to healthcare providers when they  first received SIU letters and even after their lawyers failed to reach "an amicable settlement".

 

Please contact us ASAP  to avoid your Bankruptcy, as you know exactly how this kind of healthcare SIU  foreclosure has done to your practice and your personal life:

ERISAclaim.com: Email: ERISAclaim@aol.com; Phone: 630-736-2974 (Office), 630-828-7237 (Mobile)

 

  1. Overpayment Disputes in Absence of Pure Fraud or True Overpayment, As Duplicate Payments or Erroneous Payments to Wrong Providers, Are Truly and Really Retrospective Benefits Denials, Triggering ERISA Appeal Process (ERISA Section 2560.503 to 1 (M) (Four) & DOL ERISA FAQ (12).

  2. Overpayment Causes of Action, under State Laws and Pvt. Contracts, Brought to Remedy Only Denial of Benefits, Retrospectively or Prospectively from ERISA Plans, Fall under the Scope of ERISA, Therefore Completely (100%) Preempted by ERISA in Accordance with US Supreme Court (Aetna v. Davila June 21, 2004).

  3. ERISA Claim Regulation and Each Individual ERISA Plan Provisions, Summary Plan Description (SPD), Instead of Medical Policies from a Third-Party Insurance Company or Managed-Care Network Operator, Are Governing Laws and Documents, in Accordance with US Supreme Court (01/26/2009)

  4. SIU, Medical Directors or Independent Medical Reviewers Are Prohibited from Making Direct Benefits Determination under ERISA, an ERISA Plan SPD Designated Plan Administrator or Plan Fiduciary Are the Only Authorized Party to Make Benefits Determination in Accordance with US Supreme Court (Rush Prudential HMO, Inc. v. Moran, 06/20/2002)

  5. a "Dispute regarding Any Benefits Previously Paid" from an ERISA Plan, Rather Dispute over PPO Discount, Is in the Rest of Dispute Rather Than Common-Law PPO Dispute. (Peralta v. Hispanic Business)

  6. As Legally Disclaimed by Almost Every Insurance Co., PPO/HMO Payors, Their Medical Policies are Not in Control, Each Plan Member's Plan Provision, Summary Plan Description (SPD) is Controlling and Governing Documents For All Benefits or Coverage Determination, Retrospectively or Prospectively.

  7. As Promised by Almost Every Major Insurance Co. in the Largest Class Action Settlement in the Largest U.S. Healthcare Managed Care Litigations, Re: Managed Care Litigation, Insurance Co. Will Not Use PPO/HMO or Any Managed Care Contracts to Violate ERISA Laws and Will Not Use PPO/HMO Contracts to to "Supercede, Alter or Limit" the Each Plan Member's SPD's and ERISA Laws.

  8. in Public Sectors, Medicare Claim Regulation Completely (100%) Governs Medicare Overpayment Recoupment Dispute from RAC (Recovery Auditing Contractor). In the Same Principle for Private Sectors, ERISA Laws and Claim Regulation Govern ERISA Claim Overpayment Recoupment Dispute.

  9. Failure to Defend SIU Overpayment Demand or Harassment, a Hospital or Healthcare Provider Would Have To Pay Back, Voluntarily or Involuntarily, for the Money Received Yesterday and Won't Get Paid for Any Money Tomorrow

 

Overpayment Disputes in Absence of Pure Fraud or True Overpayment, As Duplicate Payments or Erroneous Payments to Wrong Providers, Are Truly and Really Retrospective Benefits Denials, Triggering ERISA Appeal Process (ERISA Section 2560.503 to 1 (M) (Four) & DOL ERISA FAQ (12).

 

As clearly explained by Department Of Labor, in DOL ERISA FAQ C12 published on DOL website, if recouped, or refunded, for the alleged overpayment, for the payment, if any at all, for the providers at the end, "the plan, applying the plan’s limits on co-payment, deductibles, AND OVERPAYMENT REFUND, etc., pays less than 100% of the medical bills, must the plan treat its decision as an adverse benefit determination" OR A DENIAL, triggering ERISA Appeal process?

 

The DOL ERISA FAQ's Answer is "yes"!

 

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

 

DOL ERISA FAQs About The Benefit Claims Procedure Regulation

 

“C-12: If a claimant submits medical bills to a plan for reimbursement or payment, and the plan, applying the plan’s limits on co-payment, deductibles, etc., pays less than 100% of the medical bills, must the plan treat its decision as an adverse benefit determination?

 

Under the regulation, an adverse benefit determination generally includes any denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit. In any instance where the plan pays less than the total amount of expenses submitted with regard to a claim, while the plan is paying out the benefits to which the claimant is entitled under its terms, the claimant is nonetheless receiving less than full reimbursement of the submitted expenses. Therefore, in order to permit the claimant to challenge the plan’s calculation of how much it is required to pay, the decision is treated as an adverse benefit determination under the regulation. Providing the claimant with the required notification of adverse benefit determination will give the claimant the information necessary to understand why the plan has not paid the unpaid portion of the expenses and to decide whether to challenge the denial, e.g., the failure to pay in full. This approach permits claimants to  challenge whether, for example, the plan applied the wrong co-payment requirement or deductible amount. The fact that the plan believes that a claimant’s appeal will prove to be without merit does not mean that the claimant is not entitled to the procedural protections of the rule. This approach to informing claimants of their benefit entitlements with respect to specific claims, further, is consistent with current practice, in which Explanation of Benefits forms routinely describe both payable and non-payable portions of claim-related expenses. See § 2560.503-1(m)(4).”  (Emphasis added)

 

 

 

Overpayment Causes of Action, under State Laws and Pvt. Contracts, Brought to Remedy Only Denial of Benefits, Retrospectively or Prospectively from ERISA Plans, Fall under the Scope of ERISA, Therefore Completely (100%) Preempted by ERISA in Accordance with US Supreme Court (Aetna v. Davila, June 21, 2004).

 

Unanimous US Supreme Court Ruling In Overpayment Dispute

 

Aetna Health Inc. v. Davila

06/21/04

Opinion of the Court

"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."

Clearly, SIU's action "to remedy only the denial of benefits", retrospectively, under ERISA-regulated benefit plans, fall within the scope of, and are completely pre-empted by, ERISA §502(a)(1)(B)."

 

There, U.S. Supreme Court 9 Justices unanimously answered our questions if an overpayment refund action for money back from an ERISA plan is 100% ERISA dispute.

 

 

ERISA Claim Regulation and Each Individual ERISA Plan Provisions, Summary Plan Description (SPD), Instead of Medical Policies from a Third-Party Insurance Company or Managed-Care Network Operator, Are Governing Laws and Documents, in Accordance with US Supreme Court (01/26/2009)

 

SUPREME COURT OF THE UNITED STATES

KENNEDY, EXECUTRIX OF THE ESTATE OF KENNEDY,
DECEASED v. PLAN ADMINISTRATOR FOR DUPONT
SAVINGS AND INVESTMENT PLAN ET AL.


CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR
THE FIFTH CIRCUIT
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)

 

            In this case, a unanimous U.S. Supreme court ruled that ERISA plan administrator must follow ERISA and Plan documents with no exceptions to decide whom and how much benefits to pay, disregard of state laws and other private non-ERISA agreements.

 

            Although the case background was based on a divorce dispute, the ERISA law is governing law for healthcare claims as well, 100% same for all claims under ERISA. This unanimous U.S. Supreme court ruling clarifies that ERISA plan must make payments to healthcare providers and accept appeals from healthcare providers if properly authorized under ERISA disregard of any state laws, Insurance Co. or TPA Policies  or managed care  PPO/HMO contracts.

 

            This 2009 U.S. Supreme court unanimous answered our current questions if ERISA pre-empts and invalidates all PPO's and state laws!


            This is the latest 2009 U.S. Supreme Court unanimous ruling on ERISA, and plan administration, with respect to ERISA, SPD and Sate laws or PPO's (divorce agreement), that ERISA plan administrator need only look at ERISA, SPD and ERISA plan documents, to make benefits decisions, and need to care less about what other private agreement, PPO or divorce agreement, or state laws, divorce decrees in this case, because that is what Congress intended in ERISA laws since 1974, or if that is not fair or right to certain people, they can fight out of my house (ERISA Plan) and sort out their problems in state court.

 

SIU, Medical Directors or Independent Medical Reviewers Are Prohibited from Making Direct Benefits Determination under ERISA, an ERISA Plan SPD Designated Plan Administrator or Plan Fiduciary Are the Only Authorized Party to Make Benefits Determination in Accordance with US Supreme Court (Moran V. Rush Prudential)

 

SUPREME COURT OF THE UNITED STATES

 

Rush Prudential HMO, Inc. v. Moran

 

Decided June 20, 2002

The independent reviewer has no free-ranging power to construe contract terms, but instead confines review to the single phrase “medically necessary.” That reviewer must be a physician with credentials similar to those of the primary care physician and is expected to exercise independent medical judgment, based on medical records submitted by the parties, in deciding what medical necessity requires. This process does not resemble either contract interpretation or evidentiary litigation before a neutral arbiter as much as it looks like the practice of obtaining a second opinion.” (Emphasis added)

     For any utilization reviews for medical necessity, a SIU, a peer reviewer, an insurance Co.or PPO network's medical director, does not have any power or authority to make benefits or punitive action decisions, if any state laws or utilization review rules do encourage or entertain such practice as the plan did in this case, such state laws or utilization review rules will be 100% pre-empted by federal law, ERISA §502(a)(1)(B), as ruled and explained by U.S. Supreme court in  Rush Prudential HMO, Inc. v. Moran for an Illinois state law providing independent medical reviews. As the high court explained that a peer or independent reviewer has no free-ranging power under a state law to interpret ERISA plan terms or make benefits / money decisions. Such a SIU, a peer reviewer or insurer or PPO's medical director under any state Insurance laws or Code must confine his/her review to the single phrase, “medically necessary” or “coding/billing right or wrong”.

 

 

A "Dispute regarding Any Benefits Previously Paid" from an ERISA Plan, Rather Dispute over PPO Discount, Is in the Rest of Dispute Rather Than Common-Law PPO Dispute. (Peralta v. Hispanic Business)

 

To decide or determine if our dispute is common-law PPO or ERISA dispute, in Peralta v. Hispanic Business, The Ninth Circuit has explained that common law claims, or PPO claims, do not “relate to” an ERISA plan when:

1.     “the “adjudication of the claim required no interpretation of the plan”

2.     “no distribution of benefits”, and

3.     “no dispute regarding any benefits previously paid”.

 

    Therefore, A "Dispute regarding Any Benefits Previously Paid" from an ERISA Plan is completely an ERISA dispute rather than PPO/HMO discount dispute.

 

As Legally Disclaimed by Almost Every Insurance Co., PPO/HMO Payors, Their Medical Policies are Not in Control, Each Plan Member's Plan Provision, Summary Plan Description (SPD) is Controlling and Governing Documents For All Benefits or Coverage Determination, Retrospectively or Prospectively.

 

Agree to terms and conditions

 

<<http://www.aetna.com/cpb/index.html>> 

By clicking on “I Accept”, I acknowledge and accept that:

 

Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled “I Accept”.

 

While the Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits, they do not constitute a description of plan benefits. The Clinical Policy Bulletins (CPBs) express Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. ........ 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. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. The member's benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. CMS's Coverage Issues Manual can be found on the following website:

 http://cms.hhs.gov/manuals/pub06pdf/pub06pdf.asp.” (Emphasis added)

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."

As Promised by Almost Every Major Insurance Co. in the Largest Class Action Settlement in the Largest U.S. Healthcare Managed Care Litigations, Re: Managed Care Litigation, Insurance Co. Will Not Use PPO/HMO or Any Managed Care Contracts to Violate ERISA Laws and Will Not Use PPO/HMO Contracts to to "Supercede, Alter or Limit" the Each Plan Member's SPD's and ERISA Laws.

 

    As a common sense, a PPO contract is a third party contract to an ERISA plan, not an insurance Policy or plan SPD, it is not controlling and governing document for coverage and benefits dispute. As a straight forward common sense, a PPO contract is a private agreement, it can not be enforced to ""Supercede, Alter or Limit" any member's rights under ERISA, public policy.

 

ERISAclaim.com - 950,000 MD's Settled With Aetna & Cigna on ERISA

 

    Did you know that 950,000 physicians nationwide have settled and agreed with Aetna and CIGNA in their class-action lawsuit that 950,000 physicians must complete two levels of ERISA appeals as health plans internal appeals for both ERISA claims and non-ERISA claims before they can access the state protections through state external review laws?

 

A.    AETNA SETTLEMENT AGREEMENT (pdf, 97 pages), dated as of May 21, 2003 by and among AETNA INC., THE REPRESENTATIVE PLAINTIFFS, THE SIGNATORY MEDICAL SOCIETIES AND CLASS COUNSEL

 

"7.10. New Dispute Resolution Process for Physician Billing Disputes.

a."......Nothing contained in this § 7.10 is intended, or shall be construed, to supercede, alter or limit the rights or remedies otherwise available to any Person under § 502(a) of ERISA or to supercede in any respect the claims procedures of § 503 of ERISA." [page 25]

 

7.11. Medical Necessity External Review Process.

 

"(c) Notwithstanding the provisions of § 7.11(a), Physicians
may not seek review of any claim for which the Plan Member (or his or her representative) has filed suit under § 502(a) of ERISA.
In that event, or if such a suit is subsequently initiated, the Plan Member’s lawsuit shall go forward and the Physician’s claims shall be dismissed and may not be brought by or on behalf of the Physician in any forum; provided that such dismissal shall be without prejudice to any Physician seeking to establish that the rights sought to be vindicated in such lawsuit belong to such Physician and not to such Plan Member.

 

(d) Nothing contained in this § 7.11 is intended, or shall be construed, to supercede, alter or limit the rights or remedies otherwise available to any Person under § 502(a) of ERISA or to supersede in any respect the claims procedures under § 503 of ERISA.

 

e. Company shall maintain an internal appeals process for medical necessity denials and shall disclose such process on the Public Website. Company shall adjudicate all such appeals of medical necessity denials on the timeframes that are applicable to Plans subject to ERISA, regardless of whether such Plans are actually subject to ERISA......." [page 30]

 

Aetna Settlement Claim Form (pdf)

 

B.     CIGNA SETTLEMENT (pdf, 150 pages ) (doc)

 

 

"7.10 Dispute Resolution Process for Physician Billing Disputes.

a. CIGNA HealthCare shall implement an independent, external billing dispute review process (the “Billing Dispute External Review Process”) for resolving disputes with Class Members concerning the application of CIGNA HealthCare’s coding and payment rules and methodologies to (i) patient specific factual situations, including without limitation the appropriate payment amount when two or more CPT® Codes are billed together, or whether the Class Member’s use of modifiers is appropriate, or (ii) any Retained Claims, so long as such Retained Claims are submitted by the Physician to the Billing Dispute External Review Process prior to the later to occur of either ninety (90) days after Final Approval or thirty (30) days after exhaustion of CIGNA HealthCare’s internal appeals process. Each such matter shall be a “Billing Dispute.” The Reviewer (as defined below) shall not have jurisdiction over any disputes that are not patient specific application of Claim Coding and Bundling Edits, including without limitation those disputes that fall within the scope of the Medical Necessity External Review Process set forth in Section 7.11 of this Agreement, disputes about the submission of Clinical Information that fall within the scope of Section 7.12, Compliance Disputes and disputes concerning the scope of Covered Services. Nothing contained in this Section 7.10 is intended, or shall be construed, to supersede, alter or limit the rights or remedies otherwise available to any Person under § 502(a) of ERISA or to supersede in any respect the claims procedures of § 503 of ERISA.

 

"(3)       Time Limits for Completing Internal Appeals.

All internal appeals shall be completed within the time limits required by regulations  issued by the Department of Labor, even those internal appeals for which ERISA is not applicable. [page 50]

 

(3) Notwithstanding the provisions of this Section 7.11, Class Members may not seek review of any claim for which the CIGNA HealthCare Member (or his or her representative) has filed suit under § 502(a) of ERISA or other suit for the denial of health care services or supplies on Medical Necessity grounds. In that event, or if such a suit is subsequently initiated, the CIGNA HealthCare Member’s lawsuit shall go forward and the Class Member’s claims shall be dismissed and may not be brought by or on behalf of the Class Member in any forum; provided that such dismissal shall be without prejudice to any Class Member seeking to establish that the rights sought to be vindicated in such lawsuit belong to such Class Member and not to such CIGNA HealthCare Member. [page 52]


"(4)       Nothing contained in this Section 7.11 is intended, or shall be construed, to supersede, alter or limit the rights or remedies otherwise available to any Person under § 502(a) of ERISA or to supersede in any respect the claims procedures under § 503 of ERISA." [page 53] 

 

 

Anti-balance Billing Instruction to Non-participating Physicians (page 80-81)

 

"p. Participating Physician Status Dependent Upon Existence of Contracts; Limitations on Obligations of Non-Participating Physician.


CIGNA HealthCare agrees that it will treat a Class Member as a Participating Physician only in those circumstances in which the Class Member is a party to a written contract with CIGNA HealthCare or with an intermediary with which CIGNA HealthCare has a written contract. CIGNA HealthCare further agrees that at least through the Termination Date, it will not rent its networks to any other managed care company or health insurer for the purpose of providing health care services or supplies to any person who is not a CIGNA HealthCare Member; provided that nothing in this sentence shall prevent CIGNA HealthCare from making its networks available among the various current and future Subsidiaries of CIGNA Corporation; and provided, further, that nothing in this sentence shall be held to apply to a situation in which a CIGNA HealthCare customer elects to make payments on claims in respect to provisions of health care services or supplies to a CIGNA HealthCare Member through a third party administrator or where CIGNA Behavioral Health provides mental health services for another health insurance company or other entity. No affirmative obligation that this Section 7 imposes on a Participating Physician shall apply to Non-Participating Physicians unless and until, and then only to the extent that, with regard to each individual claim, such Non-Participating Physician submits or transmits to CIGNA HealthCare a claim for payment which designates therein that the Non-Participating Physician has accepted an Assignment of the CIGNA HealthCare Member’s benefits as payment for that individual claim.


q. Effect of Assignment of Benefits.


The existence of an Assignment of Benefits authorization, whether or not submitted by the Non-Participating Physician to CIGNA HealthCare, does not constitute in and of itself full or partial payment of the Non-Participating Physician’s fee (unless so agreed between the Non-Participating Physician and the CIGNA HealthCare Member), does not create an implied contract between the Non-Participating Physician and CIGNA HealthCare, and does not limit the Non-Participating Physician’s fee to any fee schedule. The Non-Participating Physician retains the right to elect either to collect the Non-Participating Physician’s full fee from the CIGNA HealthCare Member or collect partial payment from CIGNA HealthCare and the balance from the CIGNA HealthCare Member (“balance bill”)."
 

 Both Aetna and CIGNA have agreed to settle the class-action lawsuits by 950,000 physicians and agreed to process appeals in accordance with ERISA claim regulations for both ERISA claims and non-ERISA claims, and to establish external review boards for Billing and Coding Disputes, Medical Necessity Disputes and Policy Coverage Disputes, in compliance with state external review laws, however external reviews will not be available until internal appeals/ERISA appeals are completely exhausted.  

 

In Public Sectors, Medicare Claim Regulation Completely (100%) Governs Medicare Overpayment Recoupment Dispute from RAC (Recovery Auditing Contractor). In the Same Principle for Private Sectors, ERISA Laws and Claim Regulation Govern ERISA Claim Overpayment Recoupment Dispute.

 

    This simple legal principle is best explained by Medicare claim processing manual:

 

Medicare Claims Processing Manual, Chapter 29 - Appeals of Claims Decisions

 

“A post-payment review of an initial determination that results in an overpayment determination constitutes a revised initial determination”

 

<http://www.cms.hhs.gov/manuals/downloads/clm104c29.pdf>

 

CMS Medicare RAC FAQ

 

"Will the Recovery Audit Contractors (RAC) Appeal Process Mirror the Regular Medicare Appeal Process?

The Medicare Appeals process will remain the same for physicians under Part B and Part A non-inpatient claims. The only difference under Part A is for the inpatient hospital claims under the Prospective Payment System (PPS). In the current appeals process, the first level appeal will go to the Quality Improvement Organization (QIO); however, the RAC appeals will go to the Fiscal Intermediary that processed the claim."

    Failure to Defend SIU Overpayment Demand or Harassment, a Hospital or Healthcare Provider Would Have To Pay Back, Voluntarily or Involuntarily, for the Money Received Yesterday and Won't Get Paid for Any Money Tomorrow

 

    If you are a reader of this article, you should complete this part of the story with your own organizational tragic stories.

 

    We have been contacted by so many healthcare providers and even their attorneys after they already in bankruptcy or about to go into bankruptcy, from the initial SIU records request or PPO Onsite audit, many of them closed their practices and even  regretted for ever getting into practice of medicine.

 

    If a healthcare provider or a Hospital would have done ERISA compliant appeals from day one, you may not have to pay anything back and get a letter of apology at the end of your ERISA appeals for any and all of the payments you are legally entitled to under both federal and state laws.

 

    On the other hands, any non-compliant overpayment refund practice by SIU's by violating and disregarding of ERISA claim regulations and individual plan provisions could or might be the worst fraud for the century and will severely destroy U.S. health infrastructure, and defraud millions of consumers for billions of dollars. Only ERISA and Medicare Compliant overpayment refund recoupment by the payers and appeals by the providers can cut the cost, eliminate fraud and abuse and protect patients and U.S. healthcare system.

We  provide SAA (Specialty Appeal Assistance) to healthcare providers when they  first received SIU letters and  even after their lawyers failed to reach "an amicable settlement".

Email: ERISAclaim@aol.com;

Phone: 630-736-2974 (Office), 630-828-7237 (Mobile)

 

Related Links:

 

ERISAclaim.com - "Overpayment" Refund Request Response & Appeals

ERISAclaim.com - The Death of Managed Care & Health Insurance Industry UCR Fraud

ERISAclaim.com - U.S. "Healthcare $1 Trillion Crisis", You Are The Bailout Plan

ERISAclaim.com - New Medicare Overpayment Appeal - "Dr. Joe (Zhou), the RAC Invalidator"

ERISAclaim.com - ERISA or PPO? Managed Care Slavery or ERISA Superhero

ERISAclaim.com - ERISA & Your Money, Compliant Reimbursement Beyond and Above Coding/Billing + MCO Contracting

ERISAclaim.com - ERISA & Your Insanity - Healthcare Claim Reimbursement Rx from Einstein & Supreme Court

ERISAclaim.com - 950,000 MD's Settled With Aetna & Cigna on ERISA

 

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.

 

 

   
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