|
|
|
|
What's Powerful and Unique Claims
Recovery?
Rx-1
$$$$$$$$$ERISA $$$$$$$$$$
Rx-2
Are All
Consultants Corrupt? (Fast Company)
|
New Federal Health Claims & Appeals Laws
&
Regulations
for 193 Million Americans
Effective 09-23-2010
©2010, Jin
Zhou, ERISAclaim.com |
|
 |
 |
|
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 |
|
 |
 |
UNITED STATES
DEPARTMENT OF LABOR
(Links to DOL)
©2010, Jin Zhou, ERISAclaim.com |
|
Statutory Laws [PDF]
[PDF]
|
|
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)
|
|
Denials +
Recoupment =
Inflation +
Fraud or
Cost-Sharing?
Rx =
Compliant Denial & Appeals! |
|
Forbes.com: "Roughly one in seven Americans has
no health insurance. That hurts HCA Inc. (nyse:
HCA -
news
-
people), the largest U.S. hospital chain, which
last year wrote off $2.21 billion
of revenue because patients couldn't pay their
bills."
The American Hospital Association (AHA): "Hospitals today are faced with the challenge of managing their
limited resources, while continuing to deliver the highest standard of care.
According to health care experts, the cost of clinical
denials to individual healthcare organizations averages
$3.3 million
annually. However, many hospitals do not have the resources or the
expertise needed to avoid unpaid days at the end of admissions and lead the
denial-appeals processes."
Payments Go Under a Microscope (washingtonpost.com)
"MAMSI and CareFirst recoup overpayments to doctors by making
deductions from future reimbursements.
Doctors can appeal insurers' decisions.
But, in the end, they usually pay up, doctors and insurers agree."
Hospital Pricing and the Uninsured,
Glenn Melnick, Ph.D.,
"Price
Gouging"
(Subcommittee on Health
Hearing on the Uninsured,
U.S.
FILES COMPLAINT AGAINST NATIONAL ACCOUNTING FIRM UNDER FALSE CLAIMS ACT
(DOJ
Press Release) "January 5, 2004
- PHILADELPHIA
United States Attorney Patrick L. Meehan announced today the filing of the
Government's
complaint against national accounting firm Ernst & Young.
According to the complaint, nine hospitals paid Ernst & Young for billing
advice advice which later caused the submission of false claims to the
Medicare program."
USATODAY.com - Hospitals Sock Uninsured with Much Bigger Bills
GM to Report $60B in Future Health-Care Obligations
HMOs Earn $10.2 Billion in 2003,
Nearly Doubling Profits, According to Weiss Ratings; Blue Cross Blue Shield
Plans Report 63% Jump in Earnings
(BUSINESS WIRE)--Aug. 30, 2004
|
Under the federal law, ERISA, any payment less than 100% claimed or
billed is considered as a denial, including retrospective claim denials
as a result of claim audit retrospectively,
overpayment/refund request, it is a
question of whether the denial was made appropriately in accordance with
the ERISA and
governing plan document,
SPD.
Title 29 U.S.C. § 1141 states:
"It shall be unlawful for any
person through the use of fraud, force, violence, or threat of
the use of force or violence, to restrain, coerce, intimidate,
or attempt to restrain, coerce, or intimidate any participant or
beneficiary for the purpose of interfering with or preventing
the exercise of any right to which he is or may become entitled
under the plan, this title, section 3001, or the Welfare and
Pension Plans Disclosure Act. Any person who willfully violates
this section shall be fined $10,000 or imprisoned for not more
than one year, or both. The amount of fine is governed by 18
U.S.C. § 3571. The U.S. Sentencing Guidelines address 29 U.S.C.
§ 1141 under the guidelines for "Fraud and Deceit" (U.S.S.G. §
2F1.1) or for "Extortion by Force or Threat of Injury or Serious
Damage (U.S.S.G. § 2B3.2)......"
"For example, Section 1141
would reach the use of deception directed
at misleading a welfare plan beneficiary as to the amount of
health benefits owed to the beneficiary under the terms of the
plan or at misleading a pension plan participant as to
the amount of retirement benefits to which he would become
entitled under the plan upon his retirement."
ERISA in the United States Code
|
We will appeal any
denials make inappropriately and recover the money in compliance
with federal law,
ERISA and in accordance with individual
governing plan document,
SPD.
"Forty
states required individuals to first exhaust their health policys
internal appeals and grievance process before seeking external review."
(GAO, September 2003, Page 46) The health policys internal
appeals and grievance process =
ERISA
appeals 80% of the time.
Forbes.com: "Roughly one in seven Americans
has no health insurance. That hurts HCA Inc. (nyse:
HCA -
news
-
people), the largest U.S. hospital chain, which
last year wrote off $2.21 billion
of revenue because patients couldn't pay their
bills."
The American Hospital Association (AHA):
"Hospitals today are faced with the challenge of managing their limited
resources, while continuing to deliver the highest standard of care.
According to health care experts, the cost of clinical
denials to individual healthcare organizations averages
$3.3 million
annually. However, many hospitals do not have the resources or the
expertise needed to avoid unpaid days at the end of admissions and lead the
denial-appeals processes."
|
Who Can Be a Medical Reviewer under ERISA?
(Copyright © 2004
by
Jin Zhou,
ERISAclaim.com)
U.S.
SUPREME COURT
Docket for 03-83
ORAL ARGUMENT TRANSCRIPTS (page
46 0f 49)
| 02-1845.
Aetna Health Inc. v. Davila |
03/23/04 |
"QUESTION: Mr.
Estrada, you can address what you would like but there are three
points that have come up during the Respondent's presentation
that I'd be interested with a response to.
Number one, is it true
that the people who make the decisions for your client must be
medical doctors in Texas?
MR. ESTRADA:
Well it is true by virtue of DOL regulations which provide that
no claim may be turned down without input from a medical
professional in the relevant area"
|
|
New
Federal Claim Regulation (Final Rule)
-
"Plans must
consult with
appropriate health care
professionals in
deciding appealed claims
involving medical judgment."
[70268-70269,
CFR § 2560.503-1(h)(3)(iii)]
-
"The term `health care professional' means a
physician or other health care professional licensed, accredited, or
certified to perform specified health
services
consistent with State law." [page
70271
CFR § 2560.503-1(m)(7)]
-
"medical doctors in Texas"
=
MD licensed to practice medicine in Texas
for a Texas ERISA case;
-
"a medical professional in the
relevant area" = relevant area of state laws in license
jurisdiction, scope of practice and relevant local standard of care;
-
"licensed"
= licensed by the State Government/licensing board;
-
"to
perform"
= to practice medicine or health care services in the
State;
-
"specified
health services"
= medical procedures or services being reviewed or denied, instead of
file review or insurance coverage reviews
services;
-
"consistent with State law"
= consistent with State laws where the health care professional is
legally licensed to practice medicine or health care services with
respect to state jurisdictions, scope of license and state local
medical standard of care.
"The term `health care professional' means, in layman term, a
physician or other health care professional who is at least licensed in
your state (and more, board certified too) to practice the
specified/specific health services being reviewed or denied of your
claims, consistent with your state law jurisdiction, scope of practice
and local medical standard of care. Someone who is not licensed to
practice the same health care services specified/denied in your claims
is not qualified as an "appropriate health care
professionals" as defined under ERISA
§ 2560.503-1(m)(7).
Someone who is not licensed in your state to
practice "specified health services" but who is merely registered under
state or other means (URAC, IME, SSD or Peer Reviews) to do Utilization
Reviews (UR)
is not qualified as an "appropriate health care
professionals" as defined under ERISA
§ 2560.503-1(m)(7).
U.S.
Supreme Court visited ERISAclaim.com in regard to ERISA
§ 2560.503-1(h) at 11:57:03 AM on Friday,
November 21, 2003 for this No. one point.
Click here for more coverage of
Supreme Court Visiting at ERISAClaim.com.
|
|
 |
Medical Fraud Every Day?
Appeal or Re-Bill After
Denial?
You Must APPEAL
No Re-Billing!!!
Claim Appeal
or
Sentencing Appeal?
Your Choice |
|
Aetna:
Leading the Fight Against Health Care Fraud
[PDF]
View as HTML
"Thanks to this highly collaborative
relationship, we know how to identify fraud because we know what
to look for.
Medical Fraud
-
Unusual provider billing practices.
Discrepancy between the submitted diagnosis and the treatment.
Diagnoses or treatments that are outside the practitioners
scope of practice.
Claims that are resubmitted
with coding changes to gain benefits.
Alterations on claim
submissions.
Pressure for quick claim payment."
Payments Go Under a Microscope (washingtonpost.com)
January 12, 2004
"MAMSI and CareFirst
recoup overpayments to doctors by making
deductions from future reimbursements.
Doctors can appeal insurers' decisions.
But, in the end, they usually pay up, doctors and insurers
agree."
Employers Audit Workers' Health Claims
(Wall Street Journal via SFGate.com)
Excerpt: "Looking to
bring down soaring health-care costs anywhere they can, more
employers are scouring their health plans for fraud, abuse and
simple mistakes by employees or administrators.
.......The
number of requests for such audits jumped 50 percent last year,
Mr. Farley estimates."
Blue Cross and Blue Shield Association Announces New Strike
Force to Protect American Consumers from Fraud and Fight Rising
Costs (U.S.
Newswire, 4/19/2004)
"DETROIT, April 19 /U.S.
Newswire/ -- The Blue Cross and Blue Shield Association (BCBSA)
today announced a new Anti-Fraud Strike Force comprised of top
Blue Plan investigators that will work with the Federal Bureau
of Investigation (FBI) and other national, state and local law
enforcement agencies to fight major insurance fraud schemes that
rob consumers of millions of dollars annually. BCBSA President
and CEO Scott P. Serota announced the new initiative in a speech
to the Detroit Economic Club."
Clinton Township Firm Convicted of
Overbilling (Macomb
Daily)
"The case is somewhat
unusual in that a corporation was named as a criminal defendant
in the case,
but Kaiser said that is not unheard of since corporate law can
make a firm liable for criminal wrongdoing, and its principal
office holders in return are responsible for any judgments or
punishments the courts impose.
David Griem,
the defense attorney for Emergency Management who was also named
the principal to enter a guilty plea on its behalf,
also could not be reached for comment after the sentencing
hearing. In court, however, he turned over a check to the Blue
Cross insurance company officials in attendance and said the
company would pay the $5,000 court costs on time as well."
|
Health Care Fraud Report
Fiscal Year 1998
|
USDOJ: Deputy Attorney General:
Publications and Documents - - Health Care Fraud Report Fiscal
Year 1998
"On June 4,
1998, in the District of Maryland, Levindale Geriatric
Hospital paid $800,000 to resolve allegations it violated the
FCA by recoding and resubmitting denied
charges for room and board. After the claims for room and
board were denied by the Medicare Part A program, Levindale
recoded the claims as supplies, laboratory work and other
services, and submitted the claims for payment. In
addition to paying a substantial penalty under the FCA,
Levindale entered into a compliance agreement with HHS-OIG"
|
|
"A
Breaking News
950,000 MD's Settled With Aetna & Cigna on ERISA
"Aetna
and CIGNA Settlement Secrets"
"Talking
Points"
|
|
|
|
|
DOL >
EBSA >
Frequently Asked Questions |
Frequently Asked Questions about the
Benefit Claims Procedure Regulation
Under the regulation, an adverse benefit
determination generally includes any denial, reduction, or termination
of, or a failure to provide or make payment (in whole or in part) for, a
benefit. In any instance where the plan pays less than the total amount
of expenses submitted with regard to a claim, while the plan is paying
out the benefits to which the claimant is entitled under its terms, the
claimant is nonetheless receiving less than full
reimbursement of the submitted expenses. Therefore, in order to
permit the claimant to challenge the plans calculation of how much it
is required to pay, the decision is treated as an
adverse benefit determination under the regulation. Providing the
claimant with the required notification of adverse benefit determination
will give the claimant the information necessary to understand why the
plan has not paid the unpaid portion of the expenses and to decide
whether to challenge the denial, e.g., the failure to pay in full. This
approach permits claimants to challenge whether, for example, the plan
applied the wrong co-payment requirement or deductible amount.
The fact that the plan believes that a claimants
appeal will prove to be without merit does not mean that the claimant is
not entitled to the procedural protections of the rule. This
approach to informing claimants of their benefit entitlements with
respect to specific claims, further, is consistent with current
practice, in which Explanation of Benefits forms routinely describe both
payable and non-payable portions of claim-related expenses.
See § 2560.503-1(m)(4). |
|
§ 2560.503-1(m)(4). The term ``adverse benefit
determination'' means any of the following: a denial, reduction, or
termination of, or a failure to provide or make
payment (in whole or in part) for, a
benefit, including any such denial, reduction, termination, or failure
to provide or make payment that is based on a determination of a
participant's or beneficiary's eligibility to participate in a plan, and
including, with respect to group health plans, a denial, reduction, or
termination of, or a failure to provide or make payment (in
whole or in part) for, a benefit resulting from the
application of any utilization review, as
well as a failure to cover an item or service for which benefits are
otherwise provided because it is determined to be
experimental or investigational or not medically necessary or
appropriate.
|
What is ERISA Claim Recovery?
What You
Should Know about Filing Your Health Benefits Claim
ERISAclaim.com provides health-care providers, diagnostic
centers, hospitals with unique and unprecedented claim recovery services on
contingency basis for health-care ERISA claims that have been denied in
recent years and have been written off as uncollectible after every other
efforts have failed, and that have been denied recently with little or no chances
to be reimbursed from insurance companies from past experience.
We will assist you as your independent agent without any costs from you to
recover these dead accounts, difficult accounts or hopeless accounts by
appropriately appealing to insurance companies/ERISA plans in ERISA
compliant fashion.
We will not get paid unless there is a successful
recovery, on a contingency of 45% of recovered reimbursement. We
mainly focus on your "dead accounts" or "zero value" accounts after
everything you tried had failed, and that's 45% of your otherwise doing
nothing and having nothing accounts. Your 55% is much better than nothing!
Percentage may also depend upon the size of your accounts.
Please note we do not
perform traditional coding and billing services as presently performed by
your in-house and/or outside coding and billing services, therefore there's
no need for any change of your existing coding and billing business in order
to retain our claim recovery services. We primarily work with
health-care ERISA claim accounts when your
traditional coding and billing services have failed in appealing denials or
your
"squeaky wheel appeals" stopped working.
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 groundsthe largest share of denialsmay 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.
This valuable study has pointed out the direction but failed to provide
a turnkey practical solution.
Now that both
Aetna and CIGNA have
settled 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.
Aetna
(DOL/ERISA),
First Health,
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.
From
AMA's ERISA
yesterday (The latest Harvard & RAND study)
to
AMA's ERISA today (JAMA Editorial)
=ERISA Actions or Not?
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.
|
Top Seven Issues through
National Medical Specialty Societies |
|
Rank |
Problems Reported By
Popularity Rank |
% |
|
1 |
Bundling |
67% |
|
2 |
Medical Necessity Decision
Denials |
43% |
|
3 |
Prompt Payment |
43% |
|
4 |
Administrative Hassles |
33% |
|
5 |
Coding Issues |
24% |
|
6 |
Downcoding |
19% |
|
7 |
Bargaining Lack of
Negotiation Power |
14% |
|
Top Eight Most Importantly & Frequently Listed
Issues through
State Medical Associations |
|
Rank |
Problems Reported By
Importance Rank |
|
1 |
Downcoding & Bundling |
|
2 |
Prompt Payment |
|
3 |
Lack of Budgeting Power |
|
4 |
Medical Necessity Denials |
|
5 |
Prior Authorization of
Med. Services |
|
6 |
Health Plan Credentialing |
|
7 |
Drug Formularies |
|
8 |
Other |
That's why physicians,
healthcare providers and hospitals must
wake up on ERISA
now!
The
prevalent industry practice
has proven
to be risky by increasing service
charges, maximum reimbursement can only be achieved through compliance with
ERISA, among many other applicable federal and state laws and regulations.
Traditionally health-care providers and facilities have
little or no knowledge of ERISA claim procedures when dealing with
health-care claim disputes and denials. They will outsource billing
and coding to independent services in hope to recover these claims to reduce
denial rates, while most of these claim denials are not in dispute of coding
and billing, and independent coding and billing services offer only billing
and coding services. Or they will demand physicians for better
clinical documentations in hope to reverse denial decisions while
documentations are not in dispute for the denied claims. Without any
luck and success and having tried every efforts through state and national
medical associations for organized fighting back campaign with little or no
success, most of them automatically turn these denied claims to outside
consumer collection agencies to collect from patients, while collection
agency generally only collects undisputed debts instead of disputed or
denied claims for reimbursement. Under current recession economy and
escalating health cost environment,
most of these consumer collection
practice resulted little success in collecting money from patients,
but more
frustrations, and loss of marketing share with negative public relations or
possible backfiring from patients with lawsuits for medical malpractice or
consumer fraud complaints, which in turn significantly contributed to "medical
malpractice crisis", as often regarded by "tort reformers" as frivolous
malpractice lawsuits or triggering fraud investigations against hospitals
and providers.
Hospital Pricing and the Uninsured,
Glenn Melnick, Ph.D.,
"Price
Gouging"
(Subcommittee on Health
Hearing on the Uninsured,
Uninsured patients sue Advocate
Crain's Chicago Business, IL - Nov
19, 2003
A group of former patients on Wednesday sued
Oak Brook-based Advocate Health Care System, alleging the hospital chain
inflates prices for uninsured patients ...
Uninsured patients pay more for medical care
The News-Press, FL - Oct 28, 2003
"... Florida attorney general to take up its
cause, accusing hospitals of unfair and deceptive billing practices. The
organization found similar hospital billing ..."
Critical condition
Sacramento Bee, CA - Oct 26, 2003
"... the US Office of Inspector General ... who
replaced Hal Chilton as the hospital's ... in August with the US attorney's
... unnecessary procedures, then fraudulently billing ..."
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.
In year 2002
$1.55 trillion were spent in health care
business in this country, 14.9% of GDP, entire national domestic product.
One-third of health-care claims were completely denied without any
challenges, while rest of them partially and significantly denied.
Physicians and hospitals have to write off more than 30 percent of service
claims while cost of doing business and volumes of patient loads are
increasing uncontrollably. Under managed care environment, health-care
reimbursement rates have been worsening each year to a point where most
physicians and hospitals are significantly threatened and some of them
were unfortunately driven out of business.
ERISA regulates about 80% of
health-care claims, covering 6 million employee benefit plans with about 150 million Americans for more
than 28 years, while most physicians and hospitals nationwide don't even
know the existence of ERISA, let alone complying with ERISA claim procedures
in fighting against
managed care reckless claim denials.
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?
In
a letter from Republican
Congressional leader, John Boehner, to the
Secretary of Labor and
insurance/benefits industry,
he states that "specifically,
we are concerned about provisions in the final rule that
go even further than the patients' rights
bills
passed by the Congress",
and he urged DOL
to revise and delay the entire claims regulation.
Let us help you to resuscitate your reimbursement line,
restore the peace of health-care practice and recover those dead accounts
from denied claims, at least one-third of your business revenue for your
hard-working physicians and staffs, Take stress and frustration away from you
and put your true smiley faces in front of your patients.
Please e-mail for details
|
Why ERISA Claim
Recovery for Health-care Providers??? |
-
Health-care claim denial problems have
fundamentally threatened health-care providers business survival;
-
Up to 1/3 health-care claims was completely denied,
rest of them partially and significantly denied. Up to
$500 billion were denied health-care claims in 2000.
-
$1.55
trillion were spent in national health-care in
2002, 14.9% of GDP, out of which $207.2 billion were out-of-pocket
payments, rest of them are health-care claims through third party
reimbursement claims.
-
ERISA regulates about 80% of health-care claims and
is never understood by health-care providers;
-
Traditional Assignment of Benefits Form used in
hospitals and physician's offices does not provide any rights for
physicians to dispute with insurance companies over claim denials
except for only receiving undisputed and paid claims,
according to new government guidance
for new claims procedure, Q-B2;
-
New
Federal Claim Procedure, to be effective January 2002, has
provided health-care providers with
best and maximal protections against improper denials of medical
necessity, usual customary and reasonable, policy exclusion, PPO
discount and pre-existing conditions, Q-C16, Q-C17, Q-D9 & Q-D10;
-
Only with proper
understanding of what constitutes a sufficient designation of
authorized representative, as required by
new regulation, to ensure you to obtain
ERISA
rights guaranteed by federal law and to enjoy
maximal
protection to protect your business survival and prosperity.
|
|
A
New Diagnosis & Prescription for
Our
Nation's Health-care Crisis
Contrary to
the popular belief, our nation's health-care crisis has been truly
and mainly caused by the
lack of understanding and
failing in compliance with
ERISA, the federal law regulating about
80% of
health-care claims or
60% of
health expenditures in the U. S. by both
insurance/benefits
industry and health-care providers for 28 years, through reckless
and
fraudulent
as well as
revengeful, inflationary spiral
billings and
claim denials that
destroyed
or foreclosed the hope,
faith and
the Law
&
Order for our nation in health-care quality and
cost control, and the lack of meaningful and practical federal
administrative enforcement of ERISA claim regulations, because this
inflationary spiral skyrocketing increases in
managed
care claim and denial war behind
ERISA
shield between
health
insurers/ERISA plans and healthcare providers
have
overwhelmingly outnumbered increases in cost of living and national
gross domestic products, causing
annual
double-digit increases in
health
insurance premiums and
skyrocket health-care costs
($1.55
trillion
in 2002, 14.9% of the U.S GDP)
after
every managed care strategy and
model
failed to
contain or control health-care costs in long run
despite short-term savings, while entire country has devoted
more
and more money in
litigation,
legislation
and
noncompliant managed care campaign, which practically have
solved little or no problem.
In order to
resuscitate U.S. Healthcare/managed care from such a
critical
condition, the strategy and solution must to be a
common ground
acceptable to all parties involved, instead of hostile and contradictory
debate of punitive
damage therapy vs.
the uninsured coverage in
Congress. This
common ground for our national health-care crisis is the
ERISA
Claim Regulations, applicable and existing laws and regulations on
the book, originally designed by Congress in 1974 to
regulate
health-care claim dispute and to avoid fiduciary breach and
failures we are facing today.
A new practical and effective solution to
saving our
nation's health-care system is to implement
ERISA as
Congress intended by creating a new
occupation or profession, ERISA claim specialists and departments,
t0 bridge the gap FROM
medical billers and coders &
insurance claim processors TO lawyers for both health-care providers and
insurance companies/ERISA plans, and to educate everyone in
health-care and employee benefits system,
health-care
providers and their associations and leaders,
IPA's, MCO's,
health insurance, employee benefits TPA's
and legislators as well as
regulators to truly understand ERISA, and comply with
existing
ERISA's
claim procedures and benefits administration rules, to make practical
sense for health insurance delivered as
employee welfare benefits under
ERISA,
protecting participants and beneficiaries and safeguarding plan
assets through compliance of
ERISA
laws and regulations by everyone.
How do
we know this is the right diagnosis and prescription?
Plain and simple, imagine what
would happen if the U.S. healthcare superhighway transported
$1.55 trillion for 283 million Americans each year without an
understanding, without compliance by any
one and
without the enforcement of any existing
laws and
regulations governing those
80% of
the
healthcare claims,
60% of the
healthcare expenditures and
163 million Americans under
ERISA?
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."
This valuable study has pointed out the direction but failed to provide
a turnkey practical solution.
ERISAclaim.com has provided this nation with a turnkey operational
solution with ERISA compliance, to educate
everyone on ERISA, coverage and
claim
procedures, to ensure "Bill Of Rights" for Patients, Providers, Plan
Sponsors and Insurers.
|
|
Payments Go Under a Microscope (washingtonpost.com)
January 12, 2004
"CareFirst officials said the
audit of 2,800 doctors was
triggered by an earlier examination of several thousand claims
that found 9 of every 10 were
inaccurate. "The doctors, we're not saying we don't
trust them," said Jeff Valentine, a CareFirst spokesman. "But
as President Reagan said a number of years ago: 'Trust, but
verify.' "
"The largest insurer of all, the federal
government, recently estimated that the Medicare program
overpaid doctors, hospitals and other health-care providers by
$11.6 billion in 2002, according to an audit of 128,000
claims. The audit found many providers submitted
insufficient documentation (45 percent),
billed for medically unnecessary
services (22 percent) and used
incorrect codes to describe patient visits (12 percent)."
"A larger audit is
planned this year. "The digging now is much deeper,"
said Leslie V. Norwalk, chief operating officer of the Centers
for Medicare & Medicaid Services, the government agency known
as CMS. "Any dollar overpaid is a dollar too much."
"MAMSI and CareFirst recoup overpayments to
doctors by making deductions from future reimbursements.
Doctors can appeal insurers'
decisions. But, in the end, they usually pay up, doctors
and insurers agree."
"January 5, 2004
- PHILADELPHIA United States Attorney Patrick L.
Meehan announced today the filing of the Government's
complaint against national accounting firm Ernst &
Young. According to the complaint, nine hospitals paid
Ernst & Young for billing advice advice which later caused
the submission of false claims to the Medicare program."
.....
"It is the responsibility of an
independent reviewer to be alert to fraud and abuse and
certainly not to ignore it," said Meehan. "In this case, as
the complaint alleges, Ernst & Young kept itself
deliberately ignorant of the facts."
Aetna:
Leading the Fight Against Health Care Fraud
[PDF]
View as HTML
"Thanks to this highly collaborative
relationship, we know how to identify fraud because we know
what to look for.
Medical Fraud
-
Unusual provider
billing practices.
Discrepancy between
the submitted diagnosis and the treatment.
Diagnoses or
treatments that are outside the practitioners scope of
practice.
Claims that are
resubmitted with coding changes to gain benefits.
Alterations on claim
submissions.
Pressure for quick
claim payment."
Labor Department Sues Corporation For Violating Federal Employee
Benefit Law (Release Date: 02/02/2004)
Effective Corporate Compliance Programs for Health Care
Organizations (pdf) (Ernst
& Young)
"An executive summary to our 52-page overview of the
government's efforts to detect and punish health care fraud and
abuse, with guidelines on how organizations can develop an
effective corporate compliance program. (Adobe Acrobat - 708K)
Strengthening Ethical Cultures: The Emerging Role of
Compliance Programs and Officers in Managed Care Organizations
(Ernst
& Young)
|
|
|
|
|
|
|
|
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. |
|
|
 |
|
ERISA Laws/Rules
|
|
|
 |
|
ERISA in US CODE
|
|
|
|
|
|
$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.
|
|
|
|
|
$37,350 ERISA Claim
|
| Health-care provider alleged medical claims
submitted to Aetna for reimbursement, Aetna asserted no receipt
of medical claims, no written denials. Health-care
provider failed to present proof of claim submission, claim
denial and ERISA claim appeals. This case was dismissed. ERISA
health-care claims are handled in federal court, state law is
generally not applicable.
|
|
|
|
|
|
|
|
Enrollee Appeals of Preservice Coverage Denials at 2 Health
Maintenance Organizations (JAMA
Abstract) |
|
|
Cash-poor UCLA hospitals hire turnaround firm
(Los
Angeles Times)
"Turnaround
firm is asked to increase efficiency and cut costs for the system,
which fiscally lags far behind its UC counterparts."
"The largest
medical system in the UC chain, UCLA Healthcare reported lower net
income than its sister campuses last fiscal year and as of Dec. 31 had
only $20,000 cash. By comparison, UC Davis had $183 million in cash,
the most systemwide.
UCLA Healthcare -- which includes two hospitals in Westwood and one in
Santa Monica -- was forced to borrow $7 million in December from the
UCLA chancellor's office to help pay bills." |
|
|
|
|
Uninsured patients sue Advocate
Crain's Chicago
Business, IL - Nov 19,
2003
A group of former patients on Wednesday sued
Oak Brook-based Advocate Health Care System, alleging the
hospital chain inflates prices for uninsured patients ...
Illinois AG opens inquiry into hospital billing practices
(St. Louis Business
Journal, MO - Oct 27, 2003)
Uninsured patients pay more for medical care
(The News-Press, FL - Oct
28, 2003)
"Florida attorney general to take up its
cause, accusing hospitals of unfair and deceptive billing
practices. The organization found similar hospital billing
... "
Advocate subject of inquiry over billing
Advocate Health Care is the focus of two state inquiries
alleging that the Oak Brook-based hospital network's billing
practices are illegal and it engages in predatory collection
practices.
Both inquires were launched in late October by Illinois
Attorney General Lisa Madigan and the Illinois Senate. In
Downers Grove, Advocate owns and operates Advocate Good
Samaritan Hospital.
Critical condition
Sacramento Bee, CA - Oct
26, 2003 |
|
|
|
|
|
|
|
