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 ERISA Claim Consulting Services

 

New Federal Health Claims & Appeals Laws & Regulations

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Effective 09-23-2010

©2010, Jin Zhou, ERISAclaim.com

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New Webinars, Seminars & Certification Classes Announced for New Federal Health Claim Appeals Regulations on July 22, 2010 from HHS, DOL & IRS, Effective On Sept. 23, 2010 for 193 Million Americans

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ERISAclaim.com - Free Webinars - New Federal Claims & Appeals Regulations, Effective Sept. 23, 2010, for 193 Million Americans

 

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ERISAclaim.com - 2010 Claim Denial & Overpayment Dispute Two-day ERISA Appeal Seminars,

 

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

Rx = Compliant Denial & Appeals!

Health Care Analysts See Bleak Outlook for Hospitals with Reimbursement Changes (The New York Times; one-time registration required)

Excerpt: "Chill is in the air for hospitals accustomed to having insurers - both public programs like Medicare and private health plans - pay ever higher prices for hospital services. That era appears to be ending, some analysts say."

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, 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."

Employers Audit Workers' Health Claims (Wall Street Journal via SFGate.com) & (MLive.com, MI)

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."

USATODAY.com - Hospitals Sock Uninsured with Much Bigger Bills

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

 

 

Breaking News

 

"Class Actions" v. "New Strike Force"

 

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

 

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

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

 

 

Maximal Reimbursement or Crisis Turnaround to Get Paid! 

 

ERISAclaim.com concentrates entirely on an unique and unprecedented approach to denial and appeals for health-care ERISA claims. Although ERISA has been in existence for 28 years and regulates about 80% of health-care claims in U.S., it was never understood by health-care providers, physicians and hospitals. 

 

We provided consulting service to individual health-care providers, clinics and hospitals on specific needs of health-care ERISA claim denials and appeals by educating, analyzing and fundamentally reengineering your claim appeal process for more effective reimbursement consistent with current federal statutes and regulations when traditional and conventional insurance appeal strategy and practice failed.

 

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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

  1. Unusual provider billing practices.

  2. Discrepancy between the submitted diagnosis and the treatment.

  3. Diagnoses or treatments that are outside the practitioner’s scope of practice.

  4. Claims that are resubmitted with coding changes to gain benefits.

  5. Alterations on claim submissions.

  6. 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."

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."

U.S. Department of Justice Seal

Health Care Fraud Report

Fiscal Year 1998

Link to Site Map

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"

 

ERISA Power Guides
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Copyright © 2004 by Jin Zhou, ERISAclaim.com, )

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)
   

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The Root of U. S. Healthcare Crisis

Jin Zhou, ERISAclaim.com

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) (KaiserNetwork.org)]  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"!

THE 9/11 COMMISSION REPORT (pdf)

 

U.S. House of Representative Seal

February 5, 2003, H. R. 957 (pdf)
February 5, 2003, H. R. 956 (pdf)

 

Norwood Introduces The Patient Protection & ERISA Clarification Acts

 

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."

 

The latest and updated RAND/Harvard Study, funded by the U.S. Department of Labor (DOL) and requested by Congress, examines the outcomes of nearly a half-million coverage requests in two large medical groups and revealed the following:

 

 

"......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.

 

 

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.

 

"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.

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.

 

This valuable study has pointed out the direction but failed to provide a turnkey practical solution.

 

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!

 

"Congress library report", "Minneapolis memorandum" and "Phoenix memorandum" should have been sufficient intelligence for executive decision-making on health-care Oct. 11 fact card.

 

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.

 

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.

 

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.

 

According to latest hospital CEOs survey conducted by American College of Health-care Executives in November 2002, of the 984 hospital CEOs respondents, 65% named reimbursement issues in top three concerns.

 

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..

 

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), 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?

 

EFS: ERISA FAILURE SYNDROME--Managed-care Nightmare

 

Frustration, Irritation, Desperation and Depression =
Classical and Definitive Clinical Signs of
ERISA FAILURE SYNDROME (EFS)

 

ERISA, FEDERAL LAW, GOVERNS AND REGULATES 80% OF HEALTHCARE CLAIMS IN THIS COUNTRY.

 

1. Expectation beyond reality-- the school does not teach what's necessary to understand the healthcare system, independent capability in reading plain English of laws and regulations necessary for basic survival;

2. Expectation against reality-- refusal in learning what wasn't taught and what is required to understand the most important knowledge and skills --- the reasonable and minimal capability in reading and understanding plain English of applicable federal and state laws, especially so in managed-care environment;

3. Expectation ignoring reality-- claims reimbursement for healthcare profession is progressively worsening everyday, more and more professionals and hospitals have become a symbol and the target of healthcare fraud and abuse investigations, most of us acted as if this didn't happen.

 

Treatment Plan:

1. ERISA Education;

2. Keep It Simple

3. Keep It Short

 

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.

 

For Maximum Reimbursement through ERISA Compliance


For Reimbursement/Financial Crisis Turnaround


To Establish in Your Medical/Healthcare Facility
The Nation's First
Departments/Division of
 

ERISA Healthcare Claim Appeals and Reimbursement

 

 

Please e-mail for details

 

Why ERISA Consulting for Health-care Providers???

  1. Health-care claim denial problems have fundamentally threatened health-care providers business survival;

  2. 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.

  3. $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.

  4. ERISA regulates about 80% of health-care claims and is never understood by health-care providers;

  5. 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;

  6. 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;

  7. 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.

  8. 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.

  9. What You Should Know about Filing Your Health Benefits Claim

 


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

 

  1. Unusual provider billing practices.

  2. Discrepancy between the submitted diagnosis and the treatment.

  3. Diagnoses or treatments that are outside the practitioner’s scope of practice.

  4. Claims that are resubmitted with coding changes to gain benefits.

  5. Alterations on claim submissions.

  6. 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)

 

What Sites Do You Visit To Keep Up with Employee Benefits Compliance and Design Developments? (BenefitsLink Wiki)

 

Text of HHS Semiannual Regulatory Agenda (PDF) (Department of Health & Human Services) 12/13/2004

 

A New Diagnosis & Solution:
EFS-- ERISA FAILURE SYNDROME--Fatality: 31 YOA
 

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, 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.

 

 

 

Conclusion or Confusion?

© 2005, Jin Zhou, ERISAclaim.com

 

ERISAclaim.com - CMS New Appeal Rules: "Overhaul of the Medicare Claims Appeals System"

 

Based on our comprehensive and diligent study of this new Medicare appeal process, and our extensive experience in ERISA claim procedure practice, and "in view of the wide span of applicability of these rules and the complex, intertwined nature of the affected appeal procedures," [page 2 of 511] it is our conclusion that our nation must recognize and create a new profession, separated from and/or in addition to traditional Coding and Billing personal:

 

"Medicare Appeals Specialist"

 

Guerrilla and weekend training without systematic and quality education will definitely fail in Medicare reimbursement because of its broad requirement and "Authorized Representative" practice with "a waiver of the assignee's right to collect payment...."

 

"Medicare Appeals Specialist" and "ERISA Claims Specialist" will be the crown of US healthcare reimbursement.

 

This is why Congress and CMS created QIC (="Appeal Specialists" with dual and "sufficient medical, legal, and other expertise", § 405.968 (c) (1) [page 394 of 511]) separated FROM and in addition to Medicare Claim Processors (Medicare FI's & Carriers), (Among the major changes required by the BIPA amendments are--......Requiring the establishment of a new appeals entity, the qualified independent contractor (QIC), to conduct “reconsiderations” of contractors’ initial determinations (including redeterminations, [page 15-16 0f 511]).

 

And this is also why Congress enacted ERISA 30 years ago to require "an appropriate named fiduciary of the plan", § 2560.503-1(h) (1), rather than a claim processor or ASO (Administrative Services Only) TPA (Third-Party Administrator) to handle ERISA health claim appeals.

 

Conclusion or Confusion? Your choice and decision.

 

Jin Zhou, ERISAclaim.com, 03/08/2005

 

Medicare New Appeal & Reimbursement Seminars

New Compliance & Challenges

Toll-Free Numbers and Websites for Your Carrier/Fiscal Intermediary

Seminar I

2 days

Seminar II

2 days

Seminar III

2 days

New Medicare Appeal Process & Mandates

v.

Former Process

New Medicare Appeal

 Strategies for

Reimbursement Success

&

  1. Documentation

  2. Fraud And Abuse

  3. Medical Review

  4. National Correct Coding Initiative (NCCI)

  5. more

New Medicare Appeal Laws  Intertwined with($183 million/y)

ERISA Claims Laws

 

 

 

 

 

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

        Selected links:

Sec. 1002.
Definitions

Sec. 1003.
Coverage

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:

Regulations

        Selected links:

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

Claims procedure.

  

 

 

ERISA Laws/Rules

ERISA in the United States Code: Cross-reference table, table of contents

 

ERISA in US CODE

 

DOL Compliance Assistance for Health Plans

 

 

AMNews through  AMA

Health plans subject to new federal appeals rules
Much-postponed regulations offer patients and doctors fairer and faster review, plus new rights, Dept. of Labor says.

 

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"

 

$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.

 


 

 


 

 

 

Study: Many HMO Disputes Are Minor (United Press International)

 

 

Enrollee Appeals of Preservice Coverage Denials at 2 Health Maintenance Organizations (JAMA Abstract)

 

 

National Compensation Survey: Employee Benefits in Private Industry in the United States, 2000 (PDF) (U.S. Department of Labor, Bureau of Labor Statistics)

 

Government Survey: Employee Benefits in Private Industry, 2003 (U.S. Department of Labor, Bureau of Labor Statistics)

 

 

Data Provide Details on Characteristics of Health Insurance of U.S. Workers (Agency for Healthcare Research and Quality)

 

 

Opinion: The Coming Crash in Health Care (Fortune.com)
"Thus it may come as a surprise to learn that the managed-care industry is dying. Oops, did we spill the beans so soon? Well, so be it. Managed care is on the way out."

 

 

University faces $2M in health care debt

"Nowak said a big part of the medical care issue is education for all people affected by it, which is a top priority of the HCC."

 

 

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."

 

 

 

Federal Employees Health Benefits Program

 

FEHB HANDBOOK

 

 

 

 

2003 Segal Health Plan Cost Trend Survey: Preliminary Findings (PDF) (The Segal Company)

 

Tiered Hospital Plans (07/29/2003) (

 

Tiered Networks for Hospital and Physician Health Care Services (Employee Benefit Research Institute)

 

Retiree Health Care Benefits: Data Collection Issues (07/29/2003)

 

Facts from EBRI: Health Insurance and the Elderly (PDF) (Employee Benefit Research Institute)

 

Excerpt: "In 2001, 32.2 percent of the elderly had employment-based health insurance coverage in addition to Medicare, up from 28.7 percent in 1987." (page 2)

 

the Foundation for Health Coverage Education (The Foundation for Health Coverage Education)

 

 

 

US Department of Justice Seal

USDOJ

 Office of the Deputy Attorney General:

Publications and Documents

 

 

USDOJ: DAG: Corporate Fraud Task Force

 

Federal Bureau of Investigation - Health Care Fraud Unit  

FBI: About the Health Care Fraud Unit

 

VideoVIDEO

 

Link to Site Map

 

Fighting Fraud & Abuse

 

 

Program Integrity Manual (PIM)

 

Examples of Fraudulent Activities

 pdf | word |

 

HHS-Office of Inspector General (OIG)

HHS-OIG-What's New

HHS-OIG-Fraud Prevention & Detection

HHS-OIG - Publications

 

 

Former uninsured patients alleged predatory collections

Chicagobusiness.com
 

Fraud Recovery and Prevention Efforts Net Over $7.5 Million

 

FAQ/Glossary, Member Services, Preferred Health Network, PHN Online,( CareFirst BlueChoice, Inc.)

DOL ERISA Talking Points

(BCBSCNY)

 

BCBS 2004 Edu Programs (pdf)

 

BCBS2003 Edu Programs (pdf)


Washington Post Examines Health Plans' Increased Scrutiny of Healthcare Providers' Claims (KaiserNetwork.org)

 

ABCNEWS.com : Huge Medical Insurance Scam Alleged

"Rarely does the FBI discuss an ongoing investigation. But the agency made an exception because this scam is so big. Insurance companies have already been hit with half a billion dollars in claims."

 

CNN.com -Transcripts:

A New Plan to Fight Terrorism? A look at Healthcare Fraud

 

Rent a Patient - Fraud Scheme

(BCBSAL)

 

KSAT.com - Health - 'Rent-A-Patient' Fraud Under Investigation

"UnitedHealth Group alone said it's told the FBI about 300 allegedly fraudulent Southern California centers."

 

State of Wisconsin - DOJ News Release

Lautenschlager Announces Public Alert on "Rent a Patient" Insurance Scams Victimizing Wisconsin Citizens and Businesses

 

Outpatient surgery centers probed for fraud (San Jose Mercury News, CA)

 

'Rent-A-Patient' Fraud Under Investigation
(NBC4.TV, CA)

 

New Boston podiatrists accused of insurance fraud (AP Wire | 03/11/2004)

 

TWO ACCUSED IN NEW BOSTON MEDICAL SCAM

(Tyler Morning Telegraph)

 

USDOJ: Deputy Attorney General: Publications and Documents - - Health Care Fraud Report Fiscal Year 1998

 

Payments Go Under a Microscope (washingtonpost.com)

 

CMS: Comprehensive Error Rate Testing (CERT) Program

 

(January 15 , 2004)

 

RECOVERY room
(MLive.com)

 

USATODAY.com - Hospitals sock uninsured with much bigger bills

 

A Booster Shot for Uninsured

"Illinois hospitals are hammering out a plan to provide free or discounted care to the uninsured"

 

Hospital group examines plan for free care (Chicagobusiness.com)

""Aggressive collection tactics with uninsured patients cost a non-profit hospital in Urbana its tax-exempt status last month. Illinois Attorney General Lisa Madigan is investigating hospitals’ dealings with the uninsured, and a Chicago alderman is talking about revoking tax breaks for hospitals that limit charity care."

 

Doctor 'scorecards' are proposed (The Wall Street Journal)

 

   
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