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