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

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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

 

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)

 

Healthcare Revenue Cycle Crisis Turnaround:

Pre-Payment Review Delays and Denials – Deemed Denial ERISA Appeals 

 

© JIN ZHOU, President,

ERISAclaim.com

April 19, 2010

New ERISA Appeal Books & Webinars Announced From ERISAcaim.com To Resuscitate Revenue Cycle Crisis With Right Federal Law Magic. Providers Are Seemingly Left With No Common Remedies In Wake Of Financial Debilitating Overpayment Demand And Recoupment From Payers, An Increasing Number Of Healthcare Providers Are Also Facing Bankrupting Pre-Payment Review Delays For Up To Over A Year Of No-Pays And Real Denials, In An Unprecedented U.S. Healthcare Avatar: No Payment From Insurance Companies But Pay Back To Insurance Companies By Providers. Once Informed Of Pre-Payment Reviews, All State Prompt Pay Laws No Longer Apply. New ERISA Appeal Books Will provide The Most Powerful Solutions to the Pre-Payment Review Denials and Appeals

The healthcare providers are seemingly left with no common remedies in wake of financial debilitating overpayment demand and recoupment from payers, and an increasing number of healthcare providers are also facing bankrupting pre-payment review delays for up to over a year of no-pays and real denials, in an unprecedented U.S. Healthcare Avatar: no payment from insurance companies but pay more back to Insurance Companies by healthcare providers. Once informed by a payer of pre-payment reviews, all state prompt pay laws no longer apply, because no state laws will ever mandate prompt pay for disputed or non-covered claims, and state laws do not govern ERISA plans, both self-insured and fully-insured employment-based health plans. Practically, many healthcare providers are now left with no meaningful remedies while hopelessly crying on sinking Pre-payment Review Titanic for inevitable bankruptcy declaration. New ERISA Appeal Books & Webinars have been announced from ERISAcaim.com to resuscitate revenue cycle crisis with right federal law magic.

 

Federal ERISA pre-empts any and all state laws and managed-care contracts in all money or benefits dispute with ERISA plans, and ERISA provides with most powerful remedies for healthcare providers and insured working Americans: under ERISA §2560.503-1(f)(2)(iii)(B), all post-service claims under pre-payment reviews with or without request for additional information must be decided within 30 with no record request from providers, or within 45 days, including 15 days after receiving the additional records, or the plan must provide claimant with a valid ERISA EOB, Explanation of Benefits, for immediate ERISA full and fair appeals for all deemed denials.

 

One of the most popular and costly misconceptions for all providers is turning to the state prompt pay laws and PPO contracts for remedies when the providers were informed by payers of pre-payment reviews and were put on Moon Project schedules. State prompt pay laws are not triggered or no longer applicable as soon as a payer takes an action to review the claim with a timely notice within the time lines as provided by the state prompt pay laws, as common sense will tell you that no state prompt pay laws will ever mandate for a payment for disputed or non-covered services.

 

More importantly, no state prompt pay laws will apply to or govern any ERISA plans, especially self-insured plans.

 

U. S. Supreme Court unanimously and repeatedly ruled that federal law, ERISA, completely pre-empts all state laws in all benefits dispute with an ERISA plan in all pre-payment and post-payment benefits reviews, in Aetna v. Davila in 2004, and ERISA provides no exemptions for plan administrators to act, to make pre-payment and post-payment review decisions, in accordance with ERISA and the relevant plan documents, regardless of SIU’s (Special Investigation Unit) and PPO’s, in Kennedy v. Plan Administrator for Dupont in 2009.

 

On March 23, 2010, President Barack Obama signed into law the Patient Protection and Affordable Care Act, PPACA. Effective upon the enactment of the PPACA on 03/23/2010, every group health plan and individual policy issuer must comply with effective internal and external appeal process by incorporating or adopting ERISA claim regulation and NIAC External Review Model Act for any claim denials and overpayment dispute. effective from March 23, 2010, §2719(a)(1)(A)(C) of PPACA requires every group health plan and health insurance issuer for individual coverage to “(A) have in effect an internal claims appeal process” and “(C) allow an enrollee to review their file”, the entire claim case file or administrative file regardless if the plan is a statutory ERISA plan.

 

As one of the healthcare providers who attended ERISAclaim.com Seminars complained: 

“Since we were asked by a payer to pay back for more than $300,000 as alleged overpayment about 2 years ago, we have spent more than $60,000 to $70,000 on attorney fees in a fight over the overpayment demand, at the same time, the payer has put us on pre-payment reviews for all new claims for more than one year without any payment at all.”

ERISA §2560.503-1(f)(2)(iii)(B) Requires Plan To Make A Timely Decision In 45 Days Accordingly

 

ERISA §2560.503-1(f)(2)(iii)(B) provides in part: 

“(f) Timing of notification of benefit determination…….

 

(2) Group health plans. In the case of a group health plan, the plan administrator shall notify a claimant of the plan's benefit determination in accordance with paragraph (f)(2)(i), (f)(2)(ii), or (f)(2)(iii) of this section, as appropriate.

 

 (B) Post-service claims. In the case of a post-service claim, the plan administrator shall notify the claimant, in accordance with paragraph (g) of this section, of the plan's adverse benefit determination within a reasonable period of time, but not later than 30 days after receipt of the claim. This period may be extended one time by the plan for up to 15 days, provided that the plan administrator both determines that such an extension is necessary due to matters beyond the control of the plan and notifies the claimant, prior to the expiration of the initial 30-day period, of the circumstances requiring the extension of time and the date by which the plan expects to render a decision. If such an extension is necessary due to a failure of the claimant to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information, and the claimant shall be afforded at least 45 days from receipt of the notice within which to provide the specified information.” (Emphasis added)

 

<<http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm>>

 

DOL FAQs About The Benefit Claims Procedure Regulation

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

“C-3: If the period within which a group health claim must be decided is ending and the claimant has yet to furnish all the information necessary to decide the claim, may the plan extend the time period for deciding the claim and, if so, for how long?

 

In general, a group health plan may unilaterally extend the decision making on both pre-service and post-service claims for 15 days after the expiration of the initial period, if the administrator determines that such an extension is necessary for reasons beyond the control of the plan. There is no provision for extensions in the case of claims involving urgent care.

 

If the reason for taking the extension is the failure of the claimant to provide information necessary to decide the claim, and the claimant is so notified of this fact, the time period for making the decision is suspended (tolled) from the date of the notification to the claimant to the earlier of:

·        The date on which a response from the claimant is received by the plan

·        The date established by the plan for the furnishing of the requested information (at least 45 days)

 

The extension period (15 days) – within which a decision must be made by the plan – will begin to run from the date on which the claimant’s response is received by the plan (without regard to whether all of the requested information is provided) or, if earlier, the due date established by the plan for furnishing the requested information (at least 45 days). See §§ 2560.503-1(f)(2)(iii) (A) and (B); 2560.503-1(f)(4); 2560.503-1(i)(4). Also see 65 FR at 70250, n.21.” (Emphasis added)

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

 

DOL ERISA Claims Guidance: Filing A Claim For Your Health Or Disability Benefits

< http://www.dol.gov/ebsa/publications/filingbenefitsclaim.html>

Waiting For A Decision On Your Claim

 

As noted, ERISA sets specific periods of time for plans to evaluate your claim and inform you of the decision. The time limits are counted in calendar days, so weekends and holidays are included. These limits do not govern when the benefits must be paid or provided. If you are entitled to benefits, check your SPD for how and when benefits are paid. Plans are required to pay or provide benefits within a reasonable time after a claim is approved.

 

Post-service health claims      must be decided within a reasonable period of time, but not later than 30 days after the plan has received the claim. If, because of reasons beyond the plan’s control, more time is needed to review your request, the plan may extend the time period up to an additional 15 days. However, the plan administrator has to let you know before the end of the first 30-day period, explaining the reason for the delay, requesting any additional information needed, and advising you when a final decision is expected. If more information is requested, you have at least 45 days to supply it. The claim then must be decided no later than 15 days after you supply the additional information or the period of time given by the plan to do so ends, whichever comes first. The plan needs your consent if it wants more time after its first extension. The plan must give you notice that your claim has been denied in whole or in part (paying less than 100% of the claim) before the end of the time allotted for the decision. (Emphasis added)

< http://www.dol.gov/ebsa/publications/filingbenefitsclaim.html>

 

DOL ERISA Claims Guidance: What You Should Know About Filing Your Health Benefits Claim

< http://www.dol.gov/ebsa/publications/wyskfhbc.html>

Obtain A Copy Of Your Summary Plan Description (Often Referred To As An SPD)

 

The first step you should take - even before you are ready to file a benefit claim - is to carefully read your plan’s summary plan description. This is a document which your plan administrator must furnish to you after you join the plan. You can also request a copy from your plan administrator. The SPD gives you a detailed summary of your plan - how it works, what benefits it provides, and how they may be obtained (the process for filing your claim). The summary plan description is also required to describe your rights and protections under ERISA.

 

Waiting For A Decision On Your Claim

 

Your plan’s claims procedure should state the time within which  the plan must provide you with a decision on your claim. Be sure to look for these in your SPD. When you submit a claim to your plan, note the date and keep track of the time as you wait for a decision. Some plans may have different time periods depending on the nature of the benefit claim - such as whether the claim is for urgent care and whether the claim is filed before medical care is received or after. Some plans’ procedures allow the plan to extend the time period. Your plan’s claims procedure should provide for the plan’s notification to you of the plan’s decision on your claim for benefits. If you do not get a response from your plan within the specified time period, contact your plan administrator.” (Emphasis added)

< http://www.dol.gov/ebsa/publications/wyskfhbc.html>

 

United States Supreme Court unanimously ruled on 06/21/2004 that federal law, ERISA, governs ERISA claim denials and delays and pre-empts any and all state laws.

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."

On January, 26, 2009,     a unanimous U.S. Supreme court ruled that ERISA plan administrator must follow ERISA regulation and Plan documents with no exceptions to decide how pre-payment review and timely benefit determination decisions should be made by “the terms of the plan”. ERISA Statutes, 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 in all pre-payment reviews practice. ERISA forecloses any justification for enquiries into expressions of intent from SIU Investigators, SIU of TPA/ASO Medical Policies, and PPO guidelines, in favor of the virtues of adhering to an uncomplicated rule from ERISA as intended by Congress.

SUPREME COURT OF THE UNITED STATES
Syllabus
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......."

This 2009 U.S. Supreme court unanimous answered our current questions if ERISA pre-empts and invalidates all TPA/ASO, PPO, SIU programs and state laws!


This is the latest, highest and unanimous ruling from U.S. Supreme court.

 

Patient Protection and Affordable Care Act, PPACA §2719, went into effect upon its enactment of the act, on March 23, 2010, after President Barack Obama signed PPACA into law. PPACA §2719 requires every group health plan to comply with the established ERISA appeal process, 29 CFR, §2560.503-1:

SEC. 2719. APPEALS PROCESS.

 

`(a) Internal Claims Appeals-

 

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

 

`(A) have in effect an internal claims appeal process;

`(B) provide notice to enrollees, in a culturally and linguistically appropriate manner, of available internal and external appeals processes, and the availability of any applicable office of health insurance consumer assistance or ombudsman established under section 2793 to assist such enrollees with the appeals processes; and

`(C) allow an enrollee to review their file, to present evidence and testimony as part of the appeals process, and to receive continued coverage pending the outcome of the appeals process.

 

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

 

`(A) a group health plan and a health insurance issuer offering group health coverage shall provide an internal claims and appeals process that initially incorporates the claims and appeals procedures (including urgent claims) set forth at section 2560.503-1 of title 29, Code of Federal Regulations, as published on November 21, 2000 (65 Fed. Reg. 70256), and shall update such process in accordance with any standards established by the Secretary of Labor for such plans and issuers; and

`(B) a health insurance issuer offering individual health coverage, and any other issuer not subject to subparagraph (A), shall provide an internal claims and appeals process that initially incorporates the claims and appeals procedures set forth under applicable law (as in existence on the date of enactment of this section), and shall update such process in accordance with any standards established by the Secretary of Health and Human Services for such issuers.” (Emphasis added)

< http://thomas.loc.gov/cgi-bin/query/z?c111:H.R.3590.eas:>

Apparently, starting from March 23, 2010, §2719 (a)(1)(A)(C) of PPACA requires every group health plan and health insurance issuer for individual coverage to “(A) have in effect an internal claims appeal process” and “(C) allow an enrollee to review their file”, the entire claim case file or administrative file regardless if the plan is a statutory ERISA plan.

 

Strategies for Pre-Payment Review Delays and Denials – Deemed Denial ERISA Appeals 

 

Although specific deemed denial appeals are beyond the scope of this article, the actual appeal letter and form for deemed denial are 33 page long, the general strategies are very simple:

 

  1. No-pay or no-EOB / denial notice after 30-45 days is considered "deemed denial" as provided by ERISA claim regulation;

  2. State Prompt Pay Laws are useless or not applicable for any ERISA plans, both self-insured and full-insured (through purchase of insurance) plans, and as soon as the plan did anything within 30 days, such as pre-payment review notice, prompt pay laws are moot issues;

  3. "Deemed Denial" triggers your ERISA Miranda's Rights, ERISA Full and Fair Review - Appeals Rights, your ERISA Constitutional Rights, to fight back against any fraud and abuse by payers / TPA's as ERISA compliance initiatives;

  4. After 45 days, you should exercise your ERISA Miranda's Rights, file ERISA appeals with the Plan Administrator, to demand for disclosure and compliance from the plan and TPA's. Before the denial, you bear the burden of proof for your claims, after the denial, the plan bears the burden of proof as to why the claims were denied or not decided in a timely compliance fashion;

  5. Once "deemed denied", you are the boss, the reviewer, to review the plan's failure in compliance with ERISA, you must change from defense to offense, aggressively investigate and report to DOL/FBI any abuse and fraud by TPA's and plan administrators for any ERISA violations.

 

New Free ERISA Webinars from ERISAclaim.com will review all governing federal laws, ERISA and PPACA, for pre-payment reviews, and claim delays and denials, or ERISA deemed denials without timely decisions under ERISA §2560.503-1(f)(2)(iii)(B). Dr. Zhou will explain most compliant and effective ERISA appeals to bring payers into compliance, for a timely payment that a healthcare provider shall be legally entitled to under ERISA and relevant plan provisions.

 

New ERISA Appeal Books Will provide The Most Powerful Solution to the Pre-Payment Review Denials and Appeals, as a turn-key appeal compliance practice for providers and payers alike.

 

For any significant dollar size  in deemed denials, Dr. Jin Zhou is available for special on-site consulting to assist you with quicker solutions.

 

For more information on our ERISA Appeal CD Book and  Systems, please visit our website:  http://www.erisaclaim.com/products.htm

 

In the past 10 years, ERISAclaim.com has been the only ERISA specialized company offering the most practical and comprehensive ERISA education, consulting and publishing services for healthcare providers in administrative ERISA appeals for real problem oriented denials under the most mysterious 35-year-old federal law, ERISA. Dr. Jin Zhou, president ERISAclaim.com has been regarded as the Godfather of ERISA claims for healthcare providers by some in Professional billing and coding industry.

 

For more information or to arrange an interview, please contact Dr. Jin Zhou, president of ERISAclaim.com at 630-808-723 and ERISAclaim@aol.com or visit: <http://www.erisaclaim.com/products.htm>

 

###

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:

 

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

New Webinars Announced From ERISAcaim.com To Resuscitate Revenue Cycle Crisis With Right Federal Law Magic. Providers Are Seemingly Left With No Common Remedies In Wake Of Financial Debilitating Overpayment Demand And Recoupment From Payers, An Increasing Number Of Healthcare Providers Are Also Facing Bankrupting Pre-Payment Review Delays For Up To Over A Year Of No-Pays And Real Denials, In An Unprecedented U.S. Healthcare Avatar: No Payment From Insurance Companies But Pay Back To Insurance Companies By Providers. Once Informed Of Pre-Payment Reviews, All State Prompt Pay Laws No Longer Apply.

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

ERISAclaim.com Expanded Its Free Webinars to Cover New Obama Health Reform and Reimbursement Laws for Out-Of-Network Non-Participating Provider's Rights to Receive Insurance Reimbursement Checks Directly with Valid Assignment and Nondiscrimination Protections for Nonparticipation. New Obama Health Reform Law Mandates Every Group and Individual Health Plan to Accept Patient Assignment to Send Reimbursement Checks Directly to Providers Regardless of Participation, by Incorporating Existing Federal Law, ERISA, and in Consistent with Recent U.S. Supreme Court Orders.

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

ERISAclaim.com Is Celebrating Its Successful Webinars On New Healthcare Reimbursement Laws, Offered Since The House Passed Its Version Of Sweeping Reform Bill In Last November, And Subsequent Senate Bill With Identical Provisions For Appeals Laws. After President Obama Signed Into Law The Final Bill On March 23, 2010, Healthcare Providers Have Attended Its Daily Webinars With Overwhelming Reactions: Obama Made An Offer We Can’t Refuse, “To Receive Continued Coverage Pending The Outcome Of The Appeals Process”.

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 Webinars Announced From ERISAclaim.com To Discuss The Latest And The First Federal Court Ruling On March 18, 2010 That A PPO Participating Provider’s Lawsuit Against Anthem BCBS, For The Alleged Wrongful Overpayment Recoupment and Even Withholding From Different Patients, Is Completely Governed By Federal Law, ERISA, Rather Than PPO Contracts And State Laws. The Court Decision Was Mainly Relied Upon U.S. Supreme Court Rulings, the Federal Court Ruling Is Timely Consistent With New Obama Health Reform Laws That Mandate ERISA Appeals For All Group Health Plans And Health Providers. The Federal Court Timely Ruling and New Health Reform Law Mandates Are Vital and Crucial Guidance for a Potentially $6 Trillion Overpayment Market for Every One In Healthcare Delivery System.

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 Final Health Reform Bill Has Been Signed By President Obama Into The Law Of The Land For More Than 95% Americans, As The Most Significant Changes Since Medicare Was Created 45 Years Ago. What Does Obama Healthcare Law Mean To Healthcare Providers And Health Plans? New Free Webinars From ERISAclaim.com Was Announced To Discuss New Federal Reimbursement Law Mandates For All Group Health Plans And Health Care Providers: ERISA Internal And External Appeals, Extended Disclosure And Appeal Rights, New Federal UCR Fee Centers And New Federal Simplified, Uniform Standards For Claim Processing And Appeals.

ERISAclaim.com: 50% Savings - Healthcare Crisis Turnaround for Employers, Insurers & TPA's

 

ERISAclaim.com - A $1.0 Trillion Nuclear Solution to U.S. Health-care Crisis & $44 Trillion Budget Deficits

 

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

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

 

"These review procedures are available under ERISA to help patients get the care they deserve, quickly and without having to resort to costly and lengthy legal procedures. Clearly, a speedy and factual review aided by the expertise of the physicians involved with these two cases could have avoided the need for the courts to be involved at all," Klein said."

 

# # #

The American Benefits Council is the national trade association for companies concerned about federal legislation and regulations affecting all aspects of the employee benefits system. The Council's members represent the entire spectrum of the private employee benefits community and either sponsor directly or administer retirement and health plans covering more than 100 million Americans."

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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