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ERISA or non-ERISA Appeal?
PPO + ERISA Lawsuit
Overpayment & SIU
Prompt Pay Crisis & Rx
Medical Claim Denials
Downcoding & Bundling
Pre-existing Cond. Denial
Death of Managed Care
Healthcare Crisis Bailout
Medicare RAC Overpayment
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ERISA & Your Money
ERISA & Your Insanity
On-site Education
Rx for GM Health Crisis
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Moukawsher & Walsh, LLC
Pension and Employee Benefit Law


SPD's for FEHB

FEHB Open Season and FSA Open Season


Federal Employees Health Benefit Plan


Federal Employees Health Benefits Program
FEHB Plan Brochures


Links to Plan Brochures for 2003


Links to Plan Brochures for 2004


Links to the FEHB Open Season for 2005 Brochures




Federal Employees Health Benefits Program




TRICARE Handbook



SPD's for NJ State


for employees and retirees

January 2003  (pdf)


U.S. Healthcare Crisis Turnaround?

U.S. A.

Drs. & Hospitals Employers

$1.0 Trillion / Year

$$$ ERISA $$$

50% Savings

The Only Company with Compliant Solutions for All of You

Rx-1  $$$$$$$$$ERISA"Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance
$$$$$$$$$$  Rx-2
US Supreme Court Visits

at 11:57:03 AM on Friday, November 21, 2003


New Federal Health Claims & Appeals Laws & Regulations

for 193 Million Americans

Effective 09-23-2010

©2010, Jin Zhou,

Photo of President Gerald R. Ford signing Employee Retirement Income Security Act of 1974

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

DOL Seal - Link to DOL Home Page



(Links to DOL) ©2010, Jin Zhou,

Patient Protection and Affordable Care Act

Statutory Laws [PDF] [PDF]



Employee Retirement Income Security Act — ERISA

Webinars, Seminars & Certification Classes for New Federal Health Claim Appeals Regulations - Free Webinars - New Federal Claims & Appeals Regulations, Effective Sept. 23, 2010, for 193 Million Americans Seminars - 2010 Two-day Basic ERISA Appeal Seminars - Denials and Overpayment Appeals - 2010 PPACA & ERISA Claim Specialist Certification Programs in Chicago, Illinois  Create An Appeal Department for Your Hospital or Practice (In-house, onsite ERISA Claim Specialist Certification Programs)





ERISA Failure Syndrome

U.S. Healthcare Crisis Trilogy

(Copyright © 2004 by Jin Zhou,


Medical Killing
Medical Inflation
Insurance Robbery
"Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance

Read Making a Killing




Bar graph showing trends in hospital charges and revenues in California from 1995-2002







American Job ExportING!

Mass layoffs up in January 2004

Weirton Steel cancels 10,000

GM: $67.5 billion in 2003

One Nation under Debt: U..S. economy threatened by aging of America


Healthcare Disaster at Fault Verdict Index:

U.S. Government 30%

U.S. Employers & Insurers 30%

Healthcare Providers 30%

Consumers 10%

(ERISA Failure + Managed-Care) Destroyed US Healthcare
(ERISA Failure + Managed-Care + HSA) Invite US Federal Budget Deficit & Social Security Disasters = 100X 9/11 Attacks


GAO: Current and Emerging Fiscal and Retirement Security Challenges, American Benefits Council/MetLife Conference, Washington, DC, on January 14, 2005

  1. Rising Health care Costs Have Many Implications (Direct)

  2. Rising Healthcare Costs Have Many Implications (Indirect)


Rx-1  $$$$$$$$$ERISA"Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance
$$$$$$$$$$  Rx-2



About Us is a new provider of services concentrating uniquely on solving U.S. health care crisis, improving healthcare ERISA claim administration with regard to claim denials and appeals through ERISA compliance and education. We, with the principal and founder, Dr. Jin Zhou, are committed to providing unique and practical solutions to our nation's health care crisis, in case the Congress and the President of the United States fail to stop our health-care crisis and probable health care crash.


As nation's only ERISA concentrated claim denial and appeal compliance solution firm, we provide and deliver demystified and practical ERISA solutions where entire nation has failed in the past 34 years and when this nation is facing the worst healthcare crisis!


We will provide educational and consulting solutions to healthcare providers, clinics and hospitals for maximum reimbursement or crisis turnaround only through compliance of ERISA.

We will provide educational and consulting solutions to employers/plan sponsors, insurers and TPA's with compliance assistance to minimize administrative costs and risks through compliance of ERISA.


We will provide educational and consulting solutions to the nation to establish or restore the hope, faith and the Law & Order  for our health-care system through education and compliance of ERISA, the federal law designed to regulate about 80% of the health-care claims and 60% of the U.S. health-care expenditure, ERISA is the only "nuclear power" capable of stopping our escalating health-care costs. Compliance is the only common ground for everyone, and it is the only way that we can bail out of our worst health-care crisis since World War II.


We are located in northwestern suburb of Chicago, IL. We provide unconventional but practical solutions to our nation's health-care crisis. We work with health-care providers, employers, insurers, TPA's and regulators on the common ground of compliance of the ERISA. We believe existing ERISA is the only "nuclear power" that is capable of stopping our escalating health-care costs and uncontrollable health-care premium, the compliance of ERISA is only common ground for everyone in our economy and labor force as well as health-care industry. We are available for consulting, seminar, and executive brainstorming under the principle of compliance and solutions.



About Dr. Jin Zhou


Dr. Jin Zhou is a national speaker, consultant, author and publisher of health-care ERISA claim denials & appeals, regulation education and compliance. He pioneered, authored and published the nation's first ERISA Health-care Claim Appeal System in a CD book, and the nation's first website ( in ERISA healthcare claim denials, appeals, claim regulation education and compliance, “”.


He has taught ERISA seminars across the country in past 10 years to health-care providers, hospitals, billing and coding professionals, and managed-care organizations.  Dr. Zhou’s articles and expert advice were quoted and appeared on numerous industry professional magazines, web sites and organizations.  Dr. Jin Zhou was an orthopedic surgeon with Air Force General Hospital in China prior coming to United States in 1988. He is a licensed chiropractic physician in Illinois since 1991. In addition to his ERISA compliance and educational practice, he maintains an active clinical practice in Chicago suburb in Illinois. Dr. Zhou has been actively participating in teaching and innovative clinical research in medical science (



The Root of U. S. Healthcare Crisis

Jin Zhou,

The Hearing at Senate Committee on Finance on 3-3-04, [View Video "Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance
or Transcript (PDF) (]  revealed the mechanism, nature and extent of ERISA failure and nonenforcement as the reasons for "Growth in Bogus Health Insurance Plans Targeting Desperate Small Business Owners", as being concluded as "No the results are not good. It’s a tragedy." by Ann Combs, assistant secretary of DOL. The mechanism, nature and extent of ERISA failure and nonenforcement as presented at the Hearing are universally true and applicable to all health care claim denials and delays in managed care environment from all employer sponsored health plans as the root of U. S. healthcare crisis.


This is a 911 call on "healthcare 9/11 disaster"!



Fraud Health Care Cards
"New Strike Force"

Medical Fraud Every Day?

Appeal or Re-Bill After Denial?


No Re-Billing!!!

Claim Appeal or Sentencing Appeal?

Your Choice
Maximal Reimbursement
through ERISA Appeal &

Fraud Prevention and Compliance



e-mail us for more information


Legal Disclaimer

    The publication or information on this Website is designed to provide accurate and authoritative information in regard to the subject matter covered. It is presented and published with the understanding that the author and publisher are not engaged in rendering legal, accounting or other professional service or advice. If legal advice or other expert assistance is required, the services of a competent professional person should be sought.


    We're not employees of, or in affiliation with any governmental or regulatory agencies. is not a law firm. We do not practice law. If legal action or advice is required to successfully resolve a claim or a claim/business decision, we will refer out our client to an outside legal counsel chosen by our client.


    We do not teach, advise or participate in coding & billing of your health care claims and practice.  We advocate  appeals of your already denied claims through compliance and compliant claim processing for savings in accordance with ERISA claim regulations and applicable federal and state laws.


    Although often works in conjunction with, but completely independent from, different law firms or seminar sponsors whose practice is focused on the representation of or advising clients in health care ERISA claims dispute or compliance, those  law firms  or companies advertising on are not affiliated with or employed by or with disclaims any and all responsibility or liability for the accuracy, content, completeness, legality, reliability, or operability or availability of information or material displayed or advertised on the disclaims any responsibility for any harm resulting from downloading or accessing any information or material on the Internet linked to or through the

    Except for otherwise specifically stated, our educational and training for certification programs are not affiliated with any governmental or educational institute for the purpose of  accreditations or degrees. Our certifications are only for attendance in studying subject materials specified in each individual programs for advancing educational knowledge with respect to applicable business and  compliance.

Birthday Sept. 2,


Happy or Sad 30th Birthday To ERISA?

(Copyright © 2004 by Jin Zhou,

Sept. 2, 2004

On Sept. 2, 1974, exactly 30 years ago today, ERISA, The Employee Retirement Income Security Act, was signed into law by President Gerald R. Ford. The congressional intent in enacting ERISA was to protect employees in pension and welfare plans, to provide uniform federal protections in response to the failure of the Studebaker Co. in December 1963, with thousands of long-service employees cheated out off their promised pensions, and to preempt any state laws when the employees pension and welfare benefits were threatened. 30 years later, ERISA Failure in its compliance and enforcement left thousands of retirees without medical benefits, and resulted in a skyrocketing national healthcare expenditure explosion with 45 million uninsured and a possible national pension bailout.

ERISA Failure Syndrome

U.S. Healthcare Crisis Trilogy


Jin Zhou Identifies "ERISA Failure" That Killed U.S. Healthcare

"Failure of Imagination" Again?





ERISA Celebrates 30th Anniversary As Trouble Brews For the Pension Insurance Program (Spencer Benefits Reports)

Excerpt: "The seed for ERISA was planted with the failure of the Studebaker Company in December 1963, leaving thousands of long-service employees without their promised pensions."



ERISA Power Guides
by, Copyright © 2004)

What You Should Know about Filing
Your Health Benefits Claim (Claims Card)

Filing A Claim For Your Health Or Disability Benefits (PDF)

Patient's Rights Claims Procedure Regulation (Fact Sheet)
Benefit Claims Procedure Regulation (FAQ)
New Federal Claim Regulation (Final Rule)
Amendments to Summary Plan Description Regulations (Final Rule)

New & Interactive From DOL
New @ elaws

Health Benefits Advisor

DOL/EBSA Organization Chart/Regional and District EBSA Offices | By Topic | By Audience | By Organization | By Location  


Health Benefits Laws By State
(Interactive Tools From

Health Insurance Mandates in the States, 2004: a State-by-State Breakdown ... (PDF)
(Council for Affordable Health Insurance)


Consumer Guides for Health Insurance in Every State and the District of Columbia (Georgetown University)

View a 5-minute clip

Paper Chase "Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance - U.S. Health-care Crisis
& ERISA Criminal Enforcement

To Avoid "John Q.

Denials + Recoupment = Inflation + Fraud or Cost-Sharing?

Rx = Compliant Denial & Appeals! "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 ( "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, Tuesday, March 09, 2004)

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." - Hospitals Sock Uninsured with Much Bigger Bills

GM to Report $60B in Future Health-Care Obligations

A New Diagnosis & Solution:

ERISA Failure, Noncompliance and Nonenforcement of ERISA SPD and Claims Procedure Rules, Is the Damaged or Missing Foam on U.S. Healthcare Wings!

HMO Crisis Is Really An ERISA Crisis!

HMO & PPO Managed Care Contracting to 
Disregard & Substitute
ERISA SPD & Claims Procedure
Is The Primary & Inevitable Cause of Medical Inflation

Costly Managed Care & Medical Malpractice Lawsuits
American Job Export!


ERISA Failure Damages Are Greater Than
9/11 and Pearl Harbor Tragedies Combined

U.S. Health-care Crisis & ERISA Criminal Enforcement


(ERISA Failure + Managed-Care) Destroyed US Healthcare
(ERISA Failure + Managed-Care + HSA) Invite US Federal Budget Deficit & Social Security Disasters = 100X 9/11 Attacks


Only practical solution is to cut the skyrocketing healthcare care costs and increase the healthcare coverage and benefits at the same time without having to go to Congress to reinvent another new "Mars Project" or "Universal Uninsured Bill of Right" - "John Q. ERISA Enforcement".


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, the 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 provider, 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 U.S. healthcare superhighway transported $1.55 trillion for 280 million Americans each year without understanding, complying and enforcing 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." This valuable study has pointed out the direction but failed to provide a turnkey practical solution. has provided this nation with a turnkey operational solution with ERISA compliance, educate everyone on coverage and claim procedures, to ensure Bill Of Rights for Patients, Providers, Plan Sponsors and Insurers.




ERISA Not Insurance

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"


Aetna ERISA Settlemnt with 950,000 MD's


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."




Opinion: Cutting Costs in Half Through Better Management is Fantasy But Health Care Debate Is Real (The Hartford Courant)
Excerpt: "If a talk on economics can have a $650 billion throwaway line, Treasury Secretary Paul O'Neill delivered it.... [Treasury Secretary Paul] O'Neill was already the designated shoot-from-the-lip dreamer of the Bush administration, and this ridiculously unreachable goal ... only adds to his lore. Still, America's finance minister has a point if he meant to prod deep health care savings."


"O'Neill insists the problem is not with people, but systems - systems that invite medical errors, systems that penalize health care professionals for making honest mistakes, systems that create the mind-numbing complexity of reimbursement for providers, systems that reward too much treatment and punish efficiency."



Statutes (United States Code) 
ERISA - Title 29, Chapter 18. 

        Selected links:

Sec. 1002.

Sec. 1003.

Sec. 1022.
Summary plan description
Sec. 1104.
Fiduciary duties

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:


        Selected links:

2520.102-3 Contents of summary plan description.

Claims procedure.


Download Title 29, Chapter 18, of the United States Code ("Employee Retirement Income Security Act" or "ERISA") - From the U.S. House of Representatives downloadable U.S. Code.


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