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New Federal Health Claims & Appeals Laws & Regulations

for 193 Million Americans

Effective 09-23-2010

©2010, Jin Zhou, ERISAclaim.com

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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

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UNITED STATES

DEPARTMENT OF LABOR

(Links to DOL) ©2010, Jin Zhou, ERISAclaim.com

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Employee Retirement Income Security Act — ERISA

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

 

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

 

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

 

ERISAclaim.com - Health Reform for Out-Of-Network Providers: Receiving Insurance Checks Directly? – CD Books & Seminars on Why & How

 

ERISAclaim.com Press Release

 

 

03-20-2011

 

FOR IMMEDIATE RELEASE:

 

Doctors & Hospitals Countdown II On PPACA Health Reform Laws Deadline On July 01, 2011 - With 0.5% Of Claim Denials Appealed Reported By Congress

ERISAclaim.com Announced Its Initial Survey results of less than 0.001% PPACA Appeals Law Education by Provider Associations To Ensure Millions Of Doctors And About 5,815 Hospitals In Compliance with New Federal Appeals Laws By July 01, 2011 Deadline As PPACA Full Enforcement. This Finding Is Much Less Than 0.5% of Claim Denials Appealed (OH) Reported by Congress.

Hanover Park, IL (Vocus/PRWeb) Mar  20, 2011

 

On March 20, 2011, ERISAclaim.com announced its initial Internet Search and Survey results that less than 0.001% PPACA APPEALS LAW education by the providers’ Associations (including AMA & AHA) and provider industry to ensure millions of doctors and about 5,815 hospitals in compliance with new federal appeals laws by July 01, 2011 deadline as PPACA full enforcement. This finding is much less than 0.5% of claim denials appealed (OH) reported by Congress on March 16, 2011. New PPACA Health Reform Law Appeals Regulations went into effective on Sep. 23, 2010 with July 01, 2011 deadline as full enforcement, after President Obama singed health reform legislation into law on March 23, 2010. New PPACA Appeals Laws govern almost all non-Medicare and Medicaid healthcare claims. PPACA Appeals Laws are in less than 100 days countdown, while almost all doctors and hospitals are completely unaware of this PPACA Healthcare 911 Call, as Congress GAO revealed on March 16, 2011.

 

“Healthcare reform and healthcare delivery are not successful and completed until all healthcare claims are paid off legally,” said Dr. Jin Zhou, President of ERISAclaim.com, a national expert in PPACA & ERISA Appeals and Compliance.

 

On March 14, 2011, AMA reported that More Texas Doctors Dipping Into Personal Reserves To Keep Practices Alive (http://www.ama-assn.org/amednews/2011/03/14/bisc0314.htm)

 

After reviewing the Congressional GAO Report on 03/16/2011 on “Why GAO Did This Study” under PPACA, ERISAclaim.com conducted its own Initial Internet Search and Survey of the industry and provider organization websites, including national, state, and specialty associations, such as AMA & AHA, as well as billing and coding group website. Surprisingly, entire nation and industry have failed to have any provider education on PPACA Claims Appeals Laws, except for the Northern California Chapter of HFMA, one California Billing and Consulting Co., YF Corp, and one Provider State Association, Ohio State Chiropractic Association (OSCA), completed some types of PPACA Appeals Laws Webinar education and PPACA Claim Specialist Certification Program. Ironically, all healthcare providers’ associations only focused on the political PPACA talks and ignored any claims reimbursement law PPACA talks, when the reimbursement crisis was the main reason for PPACA legislations, according to Dr. Zhou, who conducted this historical PPACA research, after the Congressional GAO Report.

 

On March 16, 2011, Congress just reported that 39% to 59% appeals successfully reversed health insurance denials but only a small portion of denials are challenged, “Specifically, for the first quarter of calendar year 2010, Ohio data indicated that 0.5 percent of claim denials were internally appealed”.

 

U.S. GAO, (GAO-11-268 March 16, 2011): Private Health Insurance: Data on Application and Coverage Denials, reports the following in part (http://www.gao.gov/products/GAO-11-268):

 

“Why GAO Did This Study

 

The large percentage of Americans that rely on private health insurance for health care coverage could expand with enactment of the Patient Protection and Affordable Care Act (PPACA) of 2010. Until PPACA is fully implemented, some consumers seeking coverage can have their applications for enrollment denied, and those enrolled may face denials of coverage for specific medical services. PPACA required GAO to study the rates of such application and coverage denials. GAO reviewed the data available on denials of (1) applications for enrollment and (2) coverage for medical services.”

 

“Further, the data GAO reviewed indicated that coverage denials, if appealed, were frequently reversed in the consumer's favor. For example, data from four of the six states on the outcomes of appeals filed with insurers indicated that 39 percent to 59 percent of appeals resulted in the insurer reversing its original coverage denial. Data from a national study conducted by a trade association for insurance companies on the outcomes of appeals filed with states for an independent, external review indicated that coverage denials were reversed about 40 percent of the time.”

 

“Reversals of coverage denials were limited to denials for which an appeal was initiated. The data we reviewed did not allow for a systematic calculation of an “appeal rate”—the number of coverage denials for which an appeal was initiated—for several reasons, including different data sources or data years for denials and appeals data. Data from Ohio did provide limited information; specifically, for the first quarter of calendar year 2010, Ohio data indicated that 0.5 percent of claim denials were internally appealed.”

 

A copy of the GAO full report is available at: http://www.gao.gov/new.items/d11268.pdf

 

A copy of the GAO Highlights Page is available at: http://www.gao.gov/highlights/d11268high.pdf

 

PPACA Claims & Appeals Regulations govern all group health plans, ERISA and non-ERISA, and individual market claims.

 

July 01, 2011 is the deadline for full enforcement on PPACA since its effective date on Sept. 23, 2010. (http://www.dol.gov/ebsa/newsroom/tr10-02.html)

 

Complete PPACA Claims and Appeals Regulations and Guidance can be found on DOL website: http://www.dol.gov/ebsa/healthreform/

 

On March 18, 2011, ERISAclaim.com announced slate of new services to ensure millions of doctors and about 5,815 hospitals in compliance with new Federal Claims and Appeals Laws by July 01, 2011 deadline as PPACA full enforcement, to hopefully change that 0.5% appeals rates to at least 50% appeals rates under PAPCA with the same successful rates of 39% to 59% denial reversal as reported by Congress. The services complying with PPACA and ERISA included PPACA / ERISA Appeals Seminars, Overpayment Appeals, Corporate Compliance – Fraud & Abuse Preventions, Out-Of-Network Practice & Reimbursement, Pre-Payment Review Denials & Delays, SIU Denials & Delays – ERISA Pre-Emption, and all denials and delays under PPACA and federal law ERISA.

 

For more info on ERISAclaim.com’s new services: http://erisaclaim.com/products.htm

 

For a free PPACA Webinar for your Organization or Institution, please contact Dr. Jin Zhou, President of ERISAclaim.com, at 630-808-7237.

 

 

###

 

Contract:

Jin Zhou, President

ERISAclaim.com

Tel: 630-808-7237 (Mobile)

Tel: 630-736-2974 (Office)

Fax: 630-736-1439

E-mail: ERISAclaim@aol.com

website: http://www.ERISAclaim.com

 

 

Related Links:

 

In BCBS Overpayment ERISA Class Action, Provider Plaintiffs Seek For Class Certification and Remedies

ERISAclaim.com Offers Webinars To Examine Provider Plaintiffs’ Motion, Filed On March 17, 2011, In PCA v. BCBSA Et Al Class Action Lawsuit, To Certify Class, Seeking For Remedies In Injunctive Relief, Asking Court To Find That 23 BCBS Entities Violated Federal Law ERISA And BCBS Must Return Wrongfully Recouped Money.

Doctors & Hospitals Countdown On PPACA Health Reform Laws Deadline on July 01, 2011 - With 39% To 59% Winning Appeals Report From Congress

ERISAclaim.com Announced New Slate Of Services To Ensure Millions Of Doctors And About 5,815 Hospitals In Compliance with New Federal Claims and Appeals Laws By July 01, 2011 Deadline As PPACA Full Enforcement. On March 16, 2011, Congress Reported That 39% To 59% Appeals Reversed Health Insurance Denials While Only A Small Portion Of Denials Are Challenged.

Feds 2011 Report: 39% to 59% Appeals Reversed Health Insurance Denials, And New PPACA Claims Regulations Enforcement Deadline Countdown

ERISAclaim.com Announced New Webinars To Examine The 2011 Feds Report – U.S. GAO: Private Health Insurance: Data On Application And Coverage Denials Published On 03-16-2011, Indicated That 39% To 59% Of Appeals Reversed Original Coverage Denials, And To Prepare The Nation For New Federal Claims Regulations For Full Enforcement Deadline On July 01, 2011

Court Affirmed ERISA Embezzlement Convictions – Healthcare Overpayment Recovery Impact & Compliance For Self-Insured Plans

ERISAclaim.com Announced 2011 Free Webinars To Examine A Recent 9th Cir. Court Decision, USA v. Eriksen, Affirming ERISA Embezzlement Convictions, And Its Impact In Healthcare Overpayment Recoupment Market, As A Part Of The New ERISA Plan Assets Recovery Programs To Assist Self-Insured Health Plans In Compliance And Overpayment Recovery Audits.

Free Webinars On 2011 New Federal Health Claims Denials & Appeals Laws – Reimbursement Mandates Under PPACA

ERISAclaim.com Announced New Webinar Schedules For 2011 New Federal Health Claims Denials & Appeals Laws, New PPACA Mandates All Group Health Plan & Individual Market Claims, Effective On 09/23/2010 With A Deadline On July 01, 2011 As Full Enforcement Grace Period. Any Failure To Comply With PPACA By Health Providers Will Result In More Denials And Loss Of Rights To Appeal

Self-Insured Health Plans Should Have Recovered Millions Of Dollars From Billions Of Dollars In TPA’s Overpayment Recoupment Practice

ERISAclaim.com Announced 2011 Free Webinars And Plan Assets Recovery Programs To Assist Self-Insured Health Plans To Recover Hundreds Of Millions Of Dollars In Plan Assets From Successful TPA’s Overpayment Recovery In Billions Of Dollars, As More Than 60% Of TPA Recovered Money Originated From Self-Insured Plans And Should Be Returned To Self-Insured Health Plans Under New DOL Contributory Plans Criminal Project.

HFMA NCA Webinar Held On Health Reform Law 2011 Mandates for Claims Reimbursement & Appeals

On Feb. 22, 2011, HFMA Northern California Chapter Held Its First 2011 Webinar On Health Reform Law 2011 Mandates For Claims Reimbursement & Appeals, Taught By ERISAclaim.Com. New Federal Claims Regulations Have Been Effective Since 09/23/2010, With An Enforcement Grace Period Until July 1, 2011 For Strict And Full Enforcement, For All Group Health Plans, Individual Policies And Healthcare Providers.

Federal Court Ruled Against BCBS in Providers Counter-Lawsuit for ERISA Violations in its Recoupment Practice

ERISAclaim.com Offers Webinars to Examine the Federal Court Ruling on Feb. 16, 2010 that Denied BCBSRI’s Motion to Dismiss Two Providers’ Counterclaim Against BCBSRI for ERISA Violation when BCBSRI Initially Sued Two Providers to Recoup the Alleged Overpayment

COCSA Joins ERISA Class Action Against UnitedHealth Group For Improper Recoupment Abuses

The Congress Of Chiropractic State Associations, COCSA, Has Voted To Join A National ERISA Class Action Filed By Pomerantz, One Of The Nation’s Preeminent Class Action Firms, Against UnitedHealth Group. In The Action, COCSA Will Be Representing Its Members, State Chiropractic Associations In All 50 States, In Combatting Alleged ERISA Violations In Overpayment Recoupment Abuses.

UnitedHealth Group Sued by Pomerantz for Improper Recoupment Practices

GlobeNewsWire (press release) - ‎Feb 2, 2011‎ 

"NEW YORK, Feb. 2, 2011 (GLOBE NEWSWIRE) -- Pomerantz Haudek Grossman & Gross LLP, one of the country's preeminent class action firms and a leader in combating the abuses of the health insurance industry, filed a class action lawsuit against UnitedHealth Group and Health Net of the Northeast, Inc. on behalf of a putative nationwide class of health care providers, as well as the Ohio State Chiropractic Association. United's acquisition of Health Net of the Northeast's health insurance business closed in December 2009, adding to United's status as the nation's largest private health plan by revenue. 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 had previously been paid as health insurance benefits."

UnitedHealth Sued in Providers' ERISA Class-Action in Overpayment Recoupment Dispute for ERISA Violations  - 02-02-2011

ERISAclaim.com Webinars to Examine the Providers' ERISA Class Action against UnitedHealth, the Nation’s Largest Health Insurer, In Overpayment Recoupment Dispute and the Potential Economic and Legal Impact on All Healthcare Providers and Hospitals As Well As Health Plans.

Federal Court Ruled against BCBS Overpayment Class-Action Counterclaims – PPO & Unjust Enrichment Claims Completely Preempted by ERISA -01-25-2011

ERISAclaim.com Webinars To Examine Federal Court Ruling Dismissing Regence BCBS Counterclaims Against Plaintiff Providers In The Largest Provider Overpayment ERISA Class Action Against 23 BCBS Entities.

Federal Court Reaffirmed Its Ruling Against BCBS In A $400,000 Overpayment Lawsuit - Free Webinars On Its Impact For Entire Healthcare Industry

On 01/19/2011, Federal Court Reaffirmed Its Earlier Ruling Against BCBSRI On 10/27/2010 In An Overpayment Lawsuit Against Two Providers. “The Court Has Not Changed Its Mind” That Federal Law ERISA Supersedes And Limits BCBSRI Overpayment Recoupment Practice. A Preliminary Injunction Against Plaintiff BCBSRI Was Issued On 11/04/2010.

Healthcare Reform Law PPACA Claim Specialists: New Legal Assignment of Benefits Required Under New Federal Provider’s Bill of Rights -01-17-2011

ERISAclaim.com Officially Released 2011 Updated Legal Assignment Of Benefits Forms And Notices To Comply With Newly Effective Federal Health Reform Law, New Provider’s Bill Of Rights Provisions Of New PPACA’s Patients Bill Of Rights, For All Healthcare Providers, To All Health Plans And Individual Insurance Policies.

Healthcare Reform Law PPACA Claim Specialists: YF Corp. Leading the Nation in Advocating Patient's Bill Of Rights & Provider’s Bill of Rights - 01-14-2011

Yolanda Flores (YF) Corp. and ERISAclaim.com Start Nation's First PPACA & ERISA Claims Specialist Certification Program Under New Health Reform Law Last Year, This Month YF Corp. Renews Its Official PPACA Mission Statement And Planning For PPACA Certification Training Throughout 2011.

2011: Healthcare Reimbursement under New Health Reform Laws - With Criminal, Prompt Pay Enforcement, And More PPACA & ERISA Claims Specialists  - 01-03-2011

Beginning on Jan 01, 2011, New Federal Claims Regulations Under Health Reform Laws, PPACA, And New Criminal & Prompt Pay Enforcement On 36 Year Old Federal ERISA Claims Regulations Are Effective For All Health Plans And Individual Policies. PPACA & ERISA Claims Specialists Will Lead Changes In 45 Year Healthcare Reimbursement History.

Are You Ready For 2011 New Federal Prompt Pay Laws Under Health Reform PPACA? – For PPACA & ERISA Claim Specialists

On Jan 01, 2011, New Federal Internal And External Prompt Pay Laws Under Health Reform Laws, PPACA, Will Be Effective For All Non-Grandfathered Health Plans And Individual Policies. ERISAclaim.com Announced New Federal Prompt Pay Law Trainings For PPACA & ERISA Claim Specialist And Free Webinars For 2011

Health Reform Law Pays For More Certified PPACA & ERISA Claim Specialists - More Healthcare Experts Ready To Cash In On New Patient’s Bill of Rights - 12-17-2010

On Dec 15, 2010, ERISAclaim.com and Yolanda Flores Corporation Entered an Agreement for PPACA & ERISA Claims Specialist Certification Training Under New Federal Health Reform Laws, Federal Claims & Appeals Regulations, Effective Sep. 23, 210, To Benefit from New Patient’s Bill of Rights & Reimbursement Protections

BCBS Overpayment Class Action Defendants Sought Testimony From The National Expert On Healthcare ERISA Appeal Compliance With ERISAclaim.com - 12-06-2010

On Dec. 6, 2010, Dr. Jin Zhou of ERISAclaim.com Received a Subpoena from 23 Blue Cross Blue Shield Entities to Testify in a Class-Action Lawsuit against Blue Cross Blue Shield over the ERISA Appeals And Overpayment Recoupment Lawsuit, As Many Plaintiffs Were Taught on ERISA Appeal Compliance from ERISAclaim.com.

12/3/2010: Group Health Plans: Are You Ready for Healthcare Reform? (PDF) (Morgan, Lewis & Bockius LLP) (Counsel for BCBS Defendants) [Page 4 of 7]

" Internal Claims and Appeals: Currently, health plans must substantially comply with the existing ERISA claims and appeals regulations. Under HCR, nongrandfathered plans must strictly adhere to the existing regulations as well as to a number of new requirements. An enforcement grace period will apply until July 2, 2011 with respect to certain of the new requirements— including the review of urgent care claims within 24 hours, new content for notices of adverse benefit determination, and the strict adherence standard—to give plans time to make necessary procedural and systems changes. Model claim denial notices have been issued by the Department of Labor (DOL); the agency is expected to issue model claims and appeals language soon.


External Review: Insured plans that are subject to a state external review process that meets the HCR requirements must comply with that process. Other plans must comply with a federal external review process. An interim enforcement safe harbor has been established for nongrandfathered self-insured plans subject to the federal external review process. If such a plan either complies with the safe harbor procedures outlined in DOL Technical Release 2010-01, or voluntarily complies with an available state external review process, enforcement action will not be taken against the plan during the interim enforcement period."

Federal Court Stopped BCBS Overpayment Withholding Claim Practice - Free Webinars On Its Impact For Entire Healthcare Industry - 11-15-2010

On 11-04-2010, Federal Court Granted, Without Objection From BCBSRI, A Preliminary Injunction Against Plaintiff Blue Cross & Blue Shield Of Rhode Island Preventing It From Withholding Any Further Payments Due To The Defendant Provider To Satisfy An Alleged Debt Of Overpayment, One Week After Court Ruled, On 10-27-2010, That Federal Law ERISA Supersedes And Limits BCBSRI Overpayment Recoupment Practice.

Federal Court Ruled Against Blue Cross Blue Shield Overpayment Recoupment Practice: “Court's ruling limits Blue Cross' potential recovery” - FREE WEBINARS ON ITS IMPACT FOR ENTIRE HEALTHCARE INDUSTRY   11-01-2010

Federal Court Ruled Against BCBSRI's Overpayment Recoupment Practice On October 27, 2010. Relied Upon Recent U.S. Supreme Court Rulings, The Court Ruled That Federal Law ERISA Limits Blue Cross 'Potential Recovery, And BCBSRI's State Law Breach Of PPO Contract Claim And Fraud Claim Are Completely Preempted By ERISA. BCBSRI’s Post-Payment Audit Is A Fiduciary Conduct Governed By Federal Law ERISA Instead Of Provider PPO Contract.

Insurance News - Pomerantz Haudek Grossman & Gross LLP Announces That Court Permits Provider ERISA Class Action to Proceed Against Blue Cross Blue Shield Companies for Improper Overpayment Demands and Forced Recoupment

 

"This is a landmark decision, with widespread implications for the health care industry," says Jin Zhou, D.C. "Providers finally have a means to fight back against insurance companies for making invalid overpayment demands." Dr. Zhou is a national ERISA consultant who, through his website, www.ERISAclaim.com, and consulting services he offers to providers and plan sponsors, has long advocated the use of ERISA to combat improper post-payment audit activities. "

For a Copy of the Court Ruling

 

PCA et al v. BCBSA et al

May 17, 2010

 

Today, Sep. 23, 2010, Date of Birth For New Obama Patient’s Bill Of Reimbursement Rights: Claims & Appeals Laws Going Into Effect    09/23/2010  Hanover Park, IL

 

Free Webinar: New Federal Laws For Overpayment Dispute Going Into Effect On Sep. 23, 2010 With External Appeals and Possible $100/Day/Patient Penalties     09/16/2010  Hanover Park, IL

 

On 36th Birthday of ERISA, Historical Obama-Appeal Seminar Announced for Sep. 23, 2010 - New Federal Appeals Laws Effective Date     09/02/2010  Hanover Park, IL

 

Webinars On New Federal Penalties In $100 / Day / Patient On Insurers, HMO’s, TPA’s & IRO’s Under External Review Laws, Effective Sept. 23, 2010 Per IRS, DOL & HHS      08/30/2010  Hanover Park, IL

 

Webinars for New Federal Appeals Laws on New EOB’s For Claims Denials, Internal And External Appeals Released On August 24, 2010 from IRS, DOL and HHS      08/26/2010  Hanover Park, IL

 

New Protections for Out-of-Network Providers Under New Federal Health Laws and Regulations – Free Webinars Announced from ERISAclaim.com     08/17/2010  Hanover Park, IL

 

New Webinars, Seminars & Certification Classes Announced for New Federal Health Claim Appeals Regulations on July 22, 2010 from HHS, DOL & Treasury    08/05/2010, Hanover Park, IL

 

New Health Reform Law Claim Denial Appeal Book Announced for Healthcare Providers to Comply with New PPACA Deadline – 09/23/2010  06/28/2010, Hanover Park, IL

 

New Health Reform Law Appeal Certification Class Announced for Hospitals to Comply with New PPACA Deadline – 09/23/2010  06/24/2010, Hanover Park, IL

 

ERISAclaim.com Webinars On Healthcare Revenue Cycle Crisis Turnaround: Pre-Payment Review Delays and Denials – Deemed Denial ERISA Appeals  04/19/2010, Hanover Park, IL

 

Health Reform for Out-Of-Network Providers: Receiving Insurance Checks Directly? – Free Webinars on Why and How  04/05/2010, Hanover Park, IL

 

Health Reform For Doctors And Hospitals: Obama Made An Offer We Can’t Refuse! - ERISAclaim.com Celebrates its Successful Webinars on New Healthcare Reimbursement Laws  04/05/2010, Hanover Park, IL

 

New Free Webinars Announced to Discuss the Latest Federal Court Overpayment Lawsuit Ruling and New Obama Health Laws for the Skyrocketing $6 Trillion Overpayment Recoupment Market 03-29-2010, Hanover Park, IL

 

New Free Obama Health Law Webinars Announced For Healthcare Providers and Health Plans on New Reimbursement Laws for Claims Processing and Appeals 03-23-2010, Hanover Park, IL

 

The New TPA ERISA Appeals Department Training Program Announced for Self-Insured Health Plan’s Denial and Appeal Management To Compliantly Contain Administrative Costs 02-11-2010, Hanover Park, IL

 

The New ERISA Overpayment Appeals And Anti-Fraud Services Announced For Healthcare Providers Through ERISA Appeals And Anti-Fraud Compliance 02-08-2010, Hanover Park, IL

 

The New Hospital ERISA Appeals Department Program Announced for Hospital In-House Denial Management and Financial Crisis Turnaround  02-08-2010, Hanover Park, IL

 

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 ERISAclaim.com 11-9-2009, Hanover Park, IL

 

ERISAclaim.com 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

 

ERISAclaim.com 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

 

ERISAclaim.com 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

 

ERISAclaim.com 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

 

ERISAclaim.com 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

 

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."

http://www.americanbenefitscouncil.org/issues/health/mischealth.htm

 

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 (http://www.stopmedicarefraud.gov)

"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 ERISAclaim.com 11-9-2009, Hanover Park, IL

 

ERISAclaim.com 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

 

ERISAclaim.com 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

 

ERISAclaim.com 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

 

ERISAclaim.com 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

 

ERISAclaim.com 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.
Definitions

Sec. 1003.
Coverage

Sec. 1022.
Summary plan description

Sec. 1027.

Retention of records
Sec. 1104.
Fiduciary duties

Sec.1106.

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:

Regulations

        Selected links:

2520.102-3 Contents of summary plan description.
2560.503-1 

Claims procedure.

 

 

   
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