Seminar Goals:

1. To Understand Basic Definitions Of ERISA Claim And SPD Regulation And Appeal Practice;
2. Sufficient Understanding of Relevant Provisions Of ERISA Claim Regulation, CFR ERISA §2560.503-1;
3. Sufficient And Advanced Understanding of  DOL Guidelines Of ERISA Claim Regulation And Appeal, DOL ERISA FAQ;
4. Sufficient And Advanced Understanding of  Relevant Provisions Of ERISA Summary Plan Description (SPD) Regulation, ERISA Version of Insurance Policy under Federal Law-SPD;
5. Advanced, Practical and Strategic Application Of The ERISA Claim And SPD Regulations In Healthcare Claim Appeals;
6. Sufficient And Advanced Understanding of Most Significant U.S. Supreme Court And Federal Court Rulings, Case Laws, For ERISA Claim Litigation And Appeals;
7. To Understand How To Quickly Identify ERISA Plans;
8. To Understand How To Identify Plan Administrator From the ERISA Plans;
9. Sufficient And Advanced Understanding of How To Read Insurance Denial Notification/EOB From ERISA Standpoint;
10. Sufficient And Advanced Understanding of  Relevant State Laws And Managed Care Regulations In Support Of ERISA Appeals;
11. Sufficient And Advanced Understanding of General Principle And Practical Applications Of Denial Fact Findings, Laws And Regulations And Appeal Strategies;
12. Sufficient And Advanced Understanding And Practice in How To Appeal Commonly Seen Denials Under ERISA In Healthcare Claims, Policy Exclusion And Limitation, Medical Necessity, UCR, Precertification/Prior Authorization, Pre-Existing Condition Exclusion, Subrogation, Coordination Of Benefits/EOB, Lack Of Documentation, Lack Of Authorization To Appeal, And More……;
13. Sufficient Understanding And Advanced Practice In  How To Appeal Claim Denials And Delays With Very Specific Allegations of ERISA Violations From Payers, Beyond and Above Coding, Billing and PPO/HMO Contracting Arguments;
14. Sufficient Understanding And Advanced Practice In How To Appeal Overpayment Recoupment Demand And Withholding/Embezzlement;
15. Sufficient Understanding And Advanced Practice In The Legal Principles And Procedures In Fraud And Abuse Prevention For Healthcare Provider And Benefits Administrators, Especially Distinguished Application In Pure Benefits And Coverage Denials v. Pure Fraud and Abuse,  And Mixed Fraud and Abuse with Benefits  Coverage Denials
16. Sufficient Understanding And Advanced Practice of Federal Law And Regulations On Indigency Policy, Discount Programs In Compliance With Federal Laws, A New Risk That Unkown to Providers In Overpayment And Fraud Disputes;
17. Sufficient Understanding And Advanced Practice In How To Communicate With Attorneys Retained By ERISA Plans And Plan Administrators Of Self-Insured Health Plans For Speedy Settlement;
18. Sufficient Understanding And Advanced Practice In How To Quickly Identify And Correctly Use The Sample Letters From ERISA Appeal CD Book From Jin Zhou Of ERISAclaim.com;
19. Based On The Individual Practice, To Identify and  Make Recommendations And Changes For Medical Practice Forms, Such As Legal Assignment Of Benefits, Medical Necessity, Financial Discount/Corporate Indigency Policy;
20. How to Write Effective Appeal Letters for Healthcare Providers Specifically in Accordance with ERISA Claim Regulation..
21. How to write Benefits Review (Appeal Response) Letters Specifically in Compliance with ERISA Claim Regulation.
22. Sufficient Hands-On Simulated Case Practice and Trainings.
23. Will Answer Any Specific Questions From The Real Claim Denials On Ongoing Basis During The Seminar.

ERISAclaim.com Press Release

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

"For The First Time In U.S. Health Care History, ERISAclaim.com Announced The Nation’s First Hospital ERISA Appeal Department Program To Provide Hospital With A Turn-Key Set-Up Training For The In-House ERISA Appeals Department To Combat Commercial Managed Care Denials, Overpayment Recoupment Crisis, And Revenue Cycle Outsourcing Dilemmas For Hospital Survival, And ERISA Compliance, In Wake Of The Latest AHA Report Of More Than $36 Billion Hospital Uncompensated Care Cost"

 

"ERISAclaim.com’s Hospital ERISA Appeals Department program starts at $50,000 for up to 5 ERISA Claim Specialists Certification training and 30-day live phone and Webinar supports. Each additional ERISA Claim Specialist costs additional $8,500. An additional six-month support starts at $50,000 and one-year support at $100,000 for ERISA Appeals Department with trained ERISA Claim Specialists.

 

ERISAclaim.com also provides ERISA Claim Specialist Certification Training Classes for non-institutional providers in major U.S. cities."

 

Hospital ERISA Appeals Deaprtment = On-site ERISA Claim Specialists Certification Training + Live Phone & Webinar Support at a Price of One of the Recovered Hospital Claims!

For a complete copy of this Press Release, click here

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."

######

Please e-mail for further notice & details

630-808-7237

Press Release:

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

For CFO's, COOs, Denial Management Dept.,
Managed Care Directors,  Contract Managers,
A/R Specialist, Reimbursement Manager,
Office Manager, Coder's/Biller's,
Patient Accounting Directors And Managers,
Risk Managers, Revenue Cycle Directors,
Claims/ Benefit Managers,

"Provider Sponsored Organization" of HMO's, IPA's &
"Integrated Health Systems/Networks"
Providers, Payers And Suppliers,
Employer, Insurer, TPA's,
Appeals Dept., HR,
and More.....

ERISAclaim.com: Effective as of 11-12-2009

The First & Only One in the Country
ERISA Claims Procedure
Comprehensive Modular
Educational Training Programs
For Every One Who Handles ERISA Healthcare Claims 

For Maximum Reimbursement through ERISA Compliance
For Reimbursement/Financial Crisis Turnaround

All National and Regional Major Accounts Will Require
ERISA Compliance by The Plan TPA's (ASO's)

To Become Nation's First Generation of

ERISA Healthcare Claim Appeals and
Reimbursement Specialists

 First ERISA Denial Management Department
For Your Hospital & Practice

 950,000 MD's Settled With Aetna & Cigna on ERISA

Schedules & Locations Are Forthcoming
Please e-mail for further notice & details

For Maximum Reimbursement through ERISA Compliance
For Reimbursement/Financial Crisis Turnaround

To Become Nation's First Generation of

ERISA Healthcare Claim Appeals and
Reimbursement Specialists
 First ERISA Denial Management Departments

Rx-1  $$$$$$$$$ERISA$$$$$$$$$$  Rx-2

Managed-Care Claim Delays & Denials? What Does an Unanimous US Supreme Court Say?

On June 21, 2004, an unanimous US Supreme Court ruled that claim processing (medical judgment, timely pay &  benefits determination)  and denials of benefits under the employer-sponsored health plans, ERISA-regulated benefit plans, for both self-insured and fully-insured (through purchase of insurance) health plans, are completely governed by federal law ERISA, that supersedes and invalidates state laws.

ERISAclaim.com: "employer-sponsored group health plans" = "ERISA-regulated benefit plans", both self-insured and fully-insured (through purchase of insurance) health plans, (ERISA - Title 29, Chapter 18.  Sec. 1002.)

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

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

"Zhou's Model of Prudent Health Care"
Are All Consultants Corrupt? (Fast Company)

Breaking News

950,000 MD's Settled With Aetna & Cigna on ERISA
"Aetna and CIGNA Settlement Secrets"
"Talking Points"

Maximal Healthcare Claim Reimbursement
through ERISA Compliance

ERISAclaim.com provides unique and unprecedented certification programs for health-care ERISA claims denials and appeals through ERISA compliance in assisting  healthcare providers, physicians, clinics and hospitals in their business survival from reimbursement crisis.

Federal Law, ERISA, regulates and governs approximately 80% of U.S. health-care claims and 60% of national health-care expenditures, while in past two decades medical coders, billers and reimbursement managers or staffs are historically and practically clueless about this ERISA statutory and regulatory superpower for their business survival and development, and no ERISA educations or trainings have been received by entire reimbursement industry, because there isn't anyone available, not even one book or resource out there practically and meaningfully  available on this most important legal subject in health-care reimbursement business and industry.

Licensing of ERISA-Covered Benefit Plan Administrator, New York State Insurance Department, January 26, 2000

 

Letter opinion per CIC §12921.9 : Discretionary Clauses, (PDF) John Garamendi, Insurance Commissioner, DEPARTMENT OF INSURANCE, STATE OF CALIFORNIA, February 26, 2004

More than 70% of healthcare claims denied or delayed each year were not because of coding or billing errors or disputes, but due to non-coding and non-billing related reasons, such as policy exclusion, medical necessity/utilization reviews, pre-existing exclusions, pre-certification, prior-authorization, PPO bundling and downcoding and "unknown" or unexplained reasons. Yet all denials and delays were handled by coding and billing staffs, while up to 80% of healthcare claims are ERISA claims and these coding and billing staffs have no training and knowledge in ERISA, coverage dispute, appeal procedures. No one seems to know what to do, but do whatever they felt need to be done - going circles and frustrations every day.

Coding and billing are less than half of the successful reimbursement practice, coding and billing are not appealing and coverage dispute practice. Many coders and billers are wonderful, non-confrontational and very sophisticated individuals, but they might be terrible and counterproductive debaters, and less than ideal legal reasoning and logical thinkers. Many financial executives are hands-free managers in reimbursement divisions.

The latest Harvard & RAND study for Congress and state legislative debate on Patients' Bills of Rights, conducted by David Studdert and Carole Roan Gresenz, study authors from the Harvard School of Public Health and RAND, funded by federal government, Department Of Labor, and Agency for Health Care Research and Quality, revealed that "little is publicly known about such appeals system", and concluded that "A majority of preservice appeals disputed choice of provider or contractual coverage issues, rather than medical necessity. Medical necessity disputes proliferate not around life-saving treatments but in areas of societal uncertainty about the legitimate boundaries of insurance coverage. Greater transparency about the coverage status of specific services, through more precise contractual language and consumer education about benefits limitations, may help to avoid a large proportion of disputes in managed care."

A JAMA Editorial commenting this study further supported the conclusion of this study and advanced the right solutions more precisely at New ERISA Claim Regulations: "Regulations issued by the Clinton administration in 2000 were designed to infuse rigor into the appeals process maintained by employer-sponsored health plans covered by the Employee Retirement Income Security Act (ERISA),¹⁰ which governs insurance arrangements for more than 150 million workers and their family members. Whether these rules will be vigorously enforced remains to be seen."

The updated Harvard & RAND study, funded by the U.S. Department of Labor (DOL), published on June 18, 2003 through Health Affairs, examined the outcomes of nearly a half-million coverage requests in two large medical groups that contract with health plans to deliver care and conduct utilization review, and discovered the urgency and necessity of expertise of ERISA claim procedure specialists. The study concludes the following in its summary and policy implications:  "....We found much higher denial rates than those previously reported.....Denials made on contractual grounds—the largest share of denials—may call for both clinical and contractual expertise. Hence, they should ideally be made by personnel who are versant in both areas. There was some evidence of this sort of dual expertise being brought to bear on coverage decisions at the two groups we studied."

"......In this environment, contractual coverage and medical-necessity issues that persist are likely to be for services that enrollees feel especially strongly about. Such consumer concerns, together with ongoing consumer protection agendas that include reforms such as guaranteed external review and right-to-sue provisions, mean that the policy importance of UR denials in managed care is unlikely to wane in the foreseeable future."

However these best experts "hired" by Congress and federal government are one step away from the complete discovery and solution. Let us fill in the missing links and connect dots in order to save our health-care system from collapsing and crisis.

First, we identify the controlling force and power in contractual policy coverage denial. The majority of Americans are covered under the employer-sponsored health-care programs in private sectors under ERISA, 80% of the claims and 60% of health expenditures are regulated under ERISA. Each individual ERISA plan offers different coverage and benefits, either self-insured or fully-insured through purchase of insurance from an insurance company. The controlling and governing document for each ERISA plan is Summary Plan Description (SPD), the rule of the game for interpreting each SPD and resolving the disputes on contractual denials is ERISA claims procedure regulations. Therefore the experts from Harvard & Rand study group discovered the importance and necessity of "contractual expertise" but aborted the solution of "contractual expertise" due to "the reasons of size or financial stress, this may be beyond the reach of smaller medical groups that have assumed responsibility for UR".

Financial burden and unavailability of this contractual expertise could be the final resolution to their study group to determine if those contractual denials were made by the plan or TPA correctly.

Clinical knowledge and expertise from those medical groups are inherited, but "contractual expertise" is missing badly for policy coverage, Summary Plan Description (SPD) and ERISA Claims Procedure for 80% of health care claims, because such ERISA contractual expertise is nowhere to be found, even for those very experienced health care attorneys and insurance coverage experts, as state law governed insurance policy dispute resolution and ERISA governed claims procedure dispute resolution are quite different, and entire country has never put ERISA into health-care practice. This is why our health-care system failed.

Another new Rand/Harvard study published on February 2004 issue of Annals of Emergency Medicine, "Disputes over coverage of emergency department services: A study of two health maintenance organizations" discovered that 90% of denial in utilization reviews were overturned on appeals, from a stratified random sample of approximately 3,500 appeals of coverage denials lodged by privately insured enrollees between 1998 and 2000 at 2 of the nation's largest HMOs. This study concludes: "The prevalence of ED cases among all appeals reflects disagreement between lay and expert judgments about what constitutes emergency care under the prudent layperson standard. The high rate at which enrollees win these appeals highlights significant disagreement in interpretation of the standard among different adjudicators within managed care organizations (medical groups and health plans). When enrollees fail to challenge denials that would be reversed on appeal, they bear the financial brunt of ambiguities in interpretation of the prudent layperson standard."

This new Rand/Harvard study warns that "Although the end result for consumers is the same in each of these cases, the messages sent by plans to consumers and medical groups are not. Goodwill payments imply inappropriate use of the ED (notwithstanding the fact that actual merit might not have been assessed). Merit-based overturns, on the other hand, signal an error in utilization review and instruct medical groups about the proper limits of coverage, instructions that medical groups cannot ignore because they must meet the cost of these claims. Hence, merit-based overturns perform a valuable signaling function, akin to the role of judicial precedent in the law. Unless plans invest additional effort in educating utilization reviewers about erroneous decisions for which they are not held financially accountable, goodwill payments of potentially meritorious cases limit opportunities to forge consensus about the limits of the prudent layperson standard and to disseminate accumulated knowledge about its meaning."

Importantly, ERISA claim regulation and definition of "claim involving urgent care", 29CFR2560.503-1 (m)(1) - Claims Procedure, has provided governing solutions to "disagreement between lay and expert judgments about what constitutes emergency care under the prudent layperson standard." for these privately insured enrollees. And "Unless plans invest additional effort in educating utilization reviewers about erroneous decisions for which they are not held financially accountable," and ERISA claim regulation and  definition of "claim involving urgent care'', goodwill solution will result in backslash for more disasters in Emergency Department across the country.

If 80% of the health-care claim and 60% of health expenditures are governed and regulated by ERISA, ERISA plan's "insurance policy" is controlled by each plan's Summary Plan Description (SPD), and each claim dispute is resolved under ERISA claims procedure regulations, such "contractual expertise", called for by our Rand/Harvard experts, must be from ERISA claim procedure specialists.

Therefore, it is absolutely clear that our nation must provide a solution to health-care crisis by urgently establishing an industry or profession that will possess not only clinical expertise but also, and more importantly, ERISA contractual expertise, ERISA claim procedure expertise.

These valuable studies have pointed out the direction but failed to provide a turnkey practical solution.

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.

All other 8 major insurance companies named in class-action lawsuits have refused to settle, even if federal court would rule for physicians, the Aetna and CIGNA settlements will be "as good as it could get" from the rest of insurers and MCO's as evidenced in Aetna and CIGNA settlements with physicians.

Unless physicians understand and complete ERISA internal appeals, all of those "a love fest" and "victories" from class-action settlements would mean a fantasy of "a love fest"  to any physicians.

A striking parallel phenomena is also true in the insurance and benefits industry, as described above for medical coding and billing personnel. With the industry compliance tips for the insurance/benefits industry, offered through AAHP in complying with new federal claim regulation, reflected the same problems but provided no practical solutions, the industry is strategically revising the rules of claim processors: "We're taking the claims processors out of the loop. They're good at what they do, but they definitely aren't lawyers. We don't necessarily want them to be making discretionary decisions", said James L. Touse, vice president and associate general counsel for BlueCross BlueShield of Tennessee, at a 2002 policy conference sponsored by the American Association of Health Plans.

That is why, starting January 1, 2003, Aetna and any other insurance companies/ERISA plans have come up with a brand-new programs,  Appeals Administration Services program, parallel to our certification program, in response to this new ERISA Storm, Real Protections for Health-care Providers and Patients, while health-care providers nationwide are still in sleeping mode pursuing moon project of protections through recycling, reinventing and salvaging the ERISA storm and protection as a result of 28 year ERISA health-care crisis and refinery process.

From medical coders and billers & insurance claim processors to lawyers for physicians and insurance companies, the occupational and professional gap is a vacuum and too huge to be ignored by both insurance industry and health-care provider industry. A new occupation or profession has to be developed to handle such huge crisis: ERISA health-care Claim Specialists and Department, to bridge the gap FROM medical coders and billers & insurance claim processors TO lawyers.

Any traditional and conventional appeals without ERISA COMPLIANCE are "squeaky wheel appeals" for any ERISA claim denials and delays, 80 percent of U.S. Healthcare claims and 60% of U.S. Healthcare expenditure.

Only appeals with full ERISA compliance will ensure maximum reimbursement or crisis turnaround at minimum cost and frustrations.

Aetna (DOL/ERISA) and Blue Cross Blue Shield are ready to comply with new federal regulation(BCBSIL) (BCBSMI) (BCBSCNY) (BCBSNE) (CareFirstBCBS) & (BCBSAL),  are you ready to get paid faster and fairer?

From Aetna's ERISA yesterday (Aetna Video Shows ERISA Patients Mistreated) to Aetna's ERISA today (DOL/ERISA) = Aetna ERISA Actions or intention in compliance and in control.

In today's progressively worsening health-care and budget crisis since World War II, any health-care executive strategy, without mastering or complying with ERISA, has been proven failing since inception of managed care practice, unless a new health-care reimbursement and compliance model is established and implemented to immediately create a new line of ERISA reimbursement personnels and occupation, "ERISA Healthcare Claim Appeals and Reimbursement Specialists and Departments", no one in this country can stop and survive our failing health care system crisis.

After a one year delay, New Federal Benefit Claims Procedure Regulation has become effective January 01, 2003 for almost all of the private group health plans. It will affect about 80% of health-care claims or 60% of health expenditures, approximately 6 million private health and welfare plans and approximately 150 Million Workers and their dependents  in the U. S..

Contrary to the popular belief, the regulation provides more protections for physicians and patients than state insurance and Prompt Pay Laws, and more protections and clarifications for insurance companies and the ERISA plan sponsors as well as the third party benefits administrators than state laws in punitive damages as proposed in Patients Bill Of Rights.

"Forty states required individuals to first exhaust their health policy’s internal appeals and grievance process before seeking external review." (GAO, September 2003, Page 46)  The health policy’s internal appeals and grievance process = ERISA appeals 80% of the time.

The Latest AMA (PSA) Managed Care Hassles Survey through nationwide state medical associations and national medical specialty societies identified the most popular and important managed-care claim denials and delays.

Any reimbursement strategy will be incomplete under current ERISA statutory and managed care environment unless ERISA appeal division and specialists are included in your reimbursement practice, as important as billers and coders, office manager, and consumer account manager, or even CFO's were initially included in your business and industry.