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New Federal Health Claims & Appeals Laws & Regulations

for 193 Million Americans

Effective 09-23-2010

©2010, Jin Zhou, ERISAclaim.com

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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

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ERISA Demystified

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Managed-Care Claim Denials & US Healthcare Crisis? What Does the Unanimous US Supreme Court Say?

 

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

 

ERISAclaim.com - Supreme Court Managed Care ERISA Watch

Aetna Health Inc. v. Davila

06/21/04

Opinion of the Court

 

"Held: Respondents’ state causes of action fall within ERISA§502(a)(1)(B), and are therefore completely pre-empted by ERISA §502 and removable to federal court. Pp. 4–20."

 

"We hold that respondents’ causes of action, brought to remedy only the denial of benefits under ERISA-regulated benefit plans, fall within the scope of, and are completely pre-empted by, ERISA §502(a)(1)(B), and thus removable to federal district court. The judgment of the Court of Appeals is reversed, and the cases are remanded for further proceedings consistent with this opinion.7 It is so ordered."

 

ERISAclaim.com

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Birthday Sept. 2,
1974
30th
Birthday

 

Happy or Sad 30th Birthday To ERISA?

(Copyright © 2004 by Jin Zhou,  ERISAclaim.com)

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 Demystified

 

1.      ERISA stands for Employee Retirement Income Security Act

2.      "Health Insurance through Employment in Private Sectors" = ERISA = 80% of health-care claims or 60% of health expenditures in the U. S.

     An ERISA-regulated “welfare plan” includes any plan or program established by an employer for the purpose of providing medical care or benefits to its employees through the purchase of insurance (fully-insured) or otherwise. An ERISA plan can be self-insured or fully-insured in private sectors. 29 U.S.C. 1002(1).

3.      Governmental plan, church plan, worker's compensation, Medicare, individual insurance policy, school plan (if under governmental and church status) and third party liability claims are exempted from ERISA.

4.      ERISA Preempts Any State Laws When It Is "Related to" An Employee Benefits Dispute (Medical Insurance Claim Dispute) =ERISA Shield

5.      ERISA Does Not Provide Any Remedy except for SPD Statutory Penalty and "Contractual Damages" (Your Medical Bills)

6.      ERISA Does Not Permit Physician’s Lawsuit Unless At Least Two Levels of Appeals Are Completed and A Legal Assignment of Right to Sue Is Obtained from the Patient.  (Legal Standing and Administrative Remedy Exhaustion)

7.      Any ERISA Appeals by Physicians Are Not Valid Unless A Legal Assignment of Benefit Is Obtained from the Patient (Q-B2,  B3)

8.      ERISA Provides the Best Disclosure from ERISA plans & Insurance Companies but Physicians Have Never Realized This Important Protection

9.      ERISA Might Be the Best Protection for Physicians If They Understand How ERISA Operates

10.   Patients Bill Of Rights (PBOR) May Never Help Physicians and Patients Unless Physicians and Patients Really Understand ERISA, Since PBOR Requires Both Internal of Two Levels  and External Appeals/Reviews before A Lawsuit Can Be Filed and Since Physicians Have Had Poor or No Understanding of Proper ERISA Internal Appeal Procedures for 28 years

11.   ERISA Is Poorly Understood by Physicians

12.   ERISA Protects Health-care Providers Who Have Legal Assignment of Benefits and Have Completed At Least Two Levels of Appeals

13.   Without A Proper Legal Assignment of Benefits and Without Full Compliance with ERISA Appeal Procedures (Q-B2, B3), Healthcare Providers Are Illegal Aliens in ERISA Land

14.   Associations for Medical and Health-care Providers, Hospitals  Across the Country Are More Responsible (At Least Equally Responsible) Than Insurance Industry/ERISA Plans in Managed Care Failure and Nightmares, Because Most of Them Never Had Intentions to Fix the Managed Care Problems and Operated under "Conflict of Interests", And Because They Have Been Absolutely Clueless About ERISA, The Federal Law Protecting Them And Regulating About 80% of Health-care Claims or 60% of Health Expenditures in the U.S., And Have No Intention To Study, Educate And Comply With ERISA And New Federal Claim Regulations, Which Has Provided The Very Protections They Are Fighting For.

15.   New Federal claim/ERISA Regulations, effective 01/01/2003, provide the most powerful protections and practical solutions for the most of our managed care problems, physicians and healthcare providers nationwide are clueless and have failed to learn and comply with New ERISA Rules to get paid promptly due to "Managed-Care Secondary Gain Syndrome".

16.   DOL, FAQ, A8 clarifies HM or PPO Discount v. ERISA Claim Denial = the Provider's HMO or PPO contractual dispute will have no effect on a claimant’s ERISA right to ERISA benefits under an ERISA plan

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

 

ERISA Related Healthcare Facts

 

1.      ERISA Regulates and Governs ERISA Claim Denials and Disputes

2.      Up to 80% of health-care claims or 60% of health expenditures in the U. S., Are ERISA Claims

3.     ERISA Governs Approximately 6 Million Private Health And Welfare Plans. These Plans Cover Approximately 150 Million Workers And Their Dependents And Hold Assets Of More Than $4.6 Trillion

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

5.   More than 208 million nonelderly Americans had insurance coverage in 2003, while 44.7 million were uninsured. the majority of Americans, 159.2 million, insured in 2003 received coverage through an employment based health plan, 42.5 million were covered by public programs, and an additional 17 million purchased policies directly from an insurer. More than 32 million Americans participated in the Medicaid or State Children’s Health Insurance Program (S-CHIP),1 and 6.9 million received their health insurance through the Tricare and CHAMPVA2 programs and other government programs for retired military and their families. (Sources of Health Insurance & Characteristics of the Uninsured: Analysis of the March 2004 CPS (PDF) - Employee Benefit Research Institute)

6.     Up to 2/3 of Healthcare claims Are Denied Nationwide Each Year (Denial/Discount) (DOL FAQ C12)

7.      Significant Percentage of Healthcare claims Are Partially Denied

8.     $1.55 trillion Are Spent in Healthcare in the U.S. in 2002, about 14.9% of Entire National Domestic Product, Two of the Four Main Causes for Escalating Health Care Costs (Extremely High Administrative Costs and Managed Care Problems) Are Directly Associated with Health Care Coverage Dispute and Claims Denials under ERISA

9.      Physicians & Hospitals Rarely Filed Valid ERISA Appeals for 30 years

10.      Physicians Are at Breaking Point in Their Business Survival As a Result of the Managed Care Nightmare and Claims Denials under ERISA Shield

11.   Most Legislative Efforts and Litigations by Physicians and Patients Failed Due to ERISA Shield and the Lack of Understanding of  ERISA by Patients and Physicians

12.  Legislation, Litigation and the Extremely High Cost Healthcare Administration Are Not Answers to Managed Care Nightmare and Physician's Business Survival Unless healthcare providers Gain A Reasonable Understanding and Practice of ERISA Claims Appeal Procedures 

13.  "The original Version" of Patient's Bill Of Rights was dead on February 5, 2003, (H. R. 956 (pdf). Norwood Introduces The Patient Protection & ERISA Clarification Acts

14.  ERISA Claim Regulation, The “Patient Rights Bill”, Went Into Effect On Jan. 01, 2003 For All Health Plans In Private Sectors, For Both Self-Insured And Fully-Insued (With Purchase Of Insurance) With Better Protections Than Physicians Dreamed

15.  ERISA Claim Regulation Was Ignored, Rejected, Misinterpreted, and Withheld by Health Care Providers and Hospital Associations, As They Did for ERISA In Past 30 years, While Managed Care Claim Denials, Skyrocket High Health-care Costs and Medical Malpractice Premiums Escalated, Association's Litigation and Patient's Bill Of Rights "Campaign" At Both Federal and State Levels Pursued Contradictorily by These Associations across the Country

16.  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

17.  "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

18.  950,000 MD's Settled With Aetna & Cigna on ERISA (ERISAclaim.com)

19.  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.

 

 

 

 

DOJ: Criminal Resource Manual 2432 Coercive or Fraudulent Interference with ERISA Rights -- 29 U.S.C. 1141

2432 Coercive or Fraudulent Interference with ERISA Rights -- 29 U.S.C. 1141

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

ERISA 510 29 USC 1140 Interference with protected rights.
ERISA 511 29 USC 1141 Coercive interference.

 

 

Brief Summary Of the New Regulation

for Physicians and ERISA Plans/TPAs

Effective Date: January 01, 2003

 

For Physicians and Health-care Providers

For Insurance Companies
ERISA Plans/TPAs

ERISA's Prompt Pay Law, better than State Prompt Pay Laws  [29 CFR § 2560.503-1 (f)(i), Page 70267-9] ERISA's Prompt Pay Law, better than State Prompt Pay Laws [29 CFR § 2560.503-1 (f)(i), Page 70267-9]
   
New Assignment of Benefit Form Required for Appeals and Claim Dispute (DOL FAQ, B2-B3) No New Legal Assignment of Benefit Form, No Obligations to Physicians and Health-care Service Providers (DOL FAQ B2), otherwise Obligations to Disclose to Both Patients and Providers (DOL FAQ B-3)
   
No written appeal, no rights, except for claims involved with urgent care. [Page 70255 & 70271] In claims involved with urgent care, physicians/health-care providers are to be considered by default as authorized representatives. [Page 70255 & 70271]
   
The regulation clarifies for the first time since 1977 and prohibits anti-assignment provisions in ERISA plans & (footnote 36). [page 70255 ] [29 CFR § 2560.503-1 (b) (4) Page 70266] Assignments by patients must be absolutely clear as to what extent and capacity, verifications are permitted & (footnote 36). (DOL FAQ B-3) [page 70255 & 70266] [29 CFR § 2560.503-1 (b) (4), Page 70266]
   
Must complete required two levels of appeals, with legal assignment of benefits and specific written request for disclosure of specific plan documents. [Page 70253] No legal assignment of benefits, no response required; no specific written request, no disclosure obligated, however failure to establish and comply with claim procedures, administrative remedies are considered to be exhausted. Lawsuit may follow. [Page 70271]
   
New protections for pre-service claims and urgent care claims against improper pre-authorization, pre-certification and utilization review as well as urgent cares. [Page 70248 & 70271] Understanding of differences in pre-service, urgent care and post-service claims will save big money in fiduciary breach liability claims and POSSIBLE medical malpractice claims[Page 70248 & 70271]
   
New definitions of relevant documents and disclosure obligations, no more medical necessity secrets, UCR fee schedule confidential [Page 70252]  [29 CFR § 2560.503-1 (h)(2)(iii) (m) (4), Page 70268, 70271] [DOL FAQ B-5] No legal assignment of benefits, no obligation to disclose to an assignee, assignment verification by the plan is allowed and protected. Update SPD and any guidelines, only use disclosable and qualified medical claim reviewers. [Page 70252]  [29 CFR § 2560.503-1 (h)(2)(iii) (m) (4), Page 70268, 70271] [DOL FAQ B-5]
   
A Full and Fair Review with new definitions and protection requires de novo reviews on two appeals by at least four different people, two different fiduciaries with ERISA plan, and two different Health-care professionals independent to the ERISA plan. [29 CFR § 2560.503-1 (h) (3)(ii)(iii)(iv)(v), Page 70268-9, (m) (8), Page 70271] [Page 70252-70253] Update SPDs with New Standards and compliance, specify and designate only qualified fiduciaries for appeals, establish new complaint appeal procedures, use only disclosable and licensed as well as certified health-care professionals for medical reviews, pre-certification and prior authorizations in every case. [29 CFR § 2560.503-1 (h) (3)(ii)(iii)(iv)(v), Page 70268-9, (m) (8), Page 70271] [Page 70252-70253]
   
New clarifications on state law preemptions and "independent" medical reviews. No preemption for state laws unless prevention of the application of the new regulation [Page 70254] Comply with both the regulation and state laws in claims involving mixed treatment and eligibility determinations and pure medical treatment decision-makings. [Page 70254]
   
New clarifications with new definitions claim denial/an adverse benefit determination  (payment<100% claimed) or Overpayment, and new protections. (DOL FAQ C-12) Overpayment vs. an adverse benefit determination, recoupment vs. appeal procedures. (DOL FAQ C-12)
   
SPDs must describe...... No SPDs, No decision making
   
Insurance company's decision-making power and disclosure obligations must be described in SPD [29 CFR 2520.102-3 (q), Page 70242] Fully-insured plans with a health insurance issuer being wholly or partially responsible for administering the plan (e.g. payment of claims) must describe insurer's role in SPD. [29 CFR 2520.102-3 (q), Page 70242]
   
Claim fiduciary, whoever makes denial appeal decisions, has duties to disclose SPD and relevant document [29 CFR § 2560.503-1 (h)(2)(iii), (3)(iii) Page 70268-9, (m) (8), Page 70271] or may face up to $110 a day penalty under "Prudent Actions by Plan Fiduciaries" and "Enforce Your Rights."  [29 CFR § 2520.102-3, Page 70243]  Claim fiduciaries or plan fiduciaries have new duties to disclose, without charge, SPD and relevant document [29 CFR § 2560.503-1 (h)(2)(iii), (3)(iii) Page 70268-9, (m) (8), Page 70271] when claim for benefits is denied or delayed, or may face up to $110 a day penalty under "Prudent Actions by Plan Fiduciaries" and "Enforce Your Rights." [29 CFR § 2520.102-3, Page 70243] 
Failure to timely make benefit determination and review decisions by the plan administrator will constitute "deemed denied" review/appeal and "deemed exhaustion of administrative remedy" under § 2560.503-1(l), ("a decision on the merits of the claim" = de novo judicial review, instead of deferential judicial review) that will forfeit or preclude the plan from "deferential review standard" on judicial review in federal court, the most important part of "ERISA Shield" on ERISA land Gilbertson v Allied Signal Inc

DOL interprets § 2560.503-1(l) through CFR accompanying supplementary information on page 70255: “The Department’s intentions in including this provision in the proposal were to clarify that the procedural minimums of the regulation are essential to procedural fairness and that a decision made in the absence of the mandated procedural protections should not be entitled to any judicial deference.”

More.... More....

 

And many more new and important provisions and protections for health-care providers and insurance companies/ERISA plans/TPA's, as well as patients and employers.

 

 

 

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)

 

 

 

 

State of Connecticut v. Health Net, Inc.,

11th Cir. 09/10/2004

State Can NOT Enforce ERISA, Publicly or Privately
(
ERISAclaim.com - Managed Care Court Watch)

 

Hawaiian Court Reverses Lower Court Ruling on ERISA Preemption of State Law on External Review

(The Supreme Court of the State of Hawaii)

Excerpt: "The Hawaiian Supreme Court ruled November 18, 2004, that a state law that gives Hawaii's insurance commissioner authority to conduct external reviews of health insurance plan decisions is 'impliedly' preempted by the Employee Retirement Income Security Act (ERISA)."

 

 

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

 

"If you are an employee or family member of an employee who receives health benefits from a health plan provided through employment in the private sector, a federal law, the Employee Retirement Income Security Act (ERISA), protects you. Among the protections, ERISA sets standards for administering these plans. Those standards require plans to give you important information about the plan and to have a fair process for handling benefit claims.

 

Below are steps you should take to file a benefit claim and what to do if your claim is denied. It is especially important to know your rights under your plan and the law if your benefit claim is denied.

Obtain a copy of your Summary Plan Description (SPD)

 

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

 

More...

 

What You Should Know about Filing Your Health Benefits Claim

 

29CFR2520.102-3 - Contents of Summary Plan Description.

 

ERISAclaim.com: Supreme Court Watch, (Rush) "It is, in fact, the Plan Administrator" (footnote 3)

 

 

How Does ERISA Protect You?

 

 

Breaking News

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

 

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

Are All Consultants Corrupt? (Fast Company)

 

ERISA Demystified

for Providers, Insurers, Employers, TPAs,
 Patients, State Regulators and Legislators

 

 

 

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

 

 

Fraud Health Care Cards

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

  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."

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."

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"

 

 

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

 

19. 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:

 

 

 

  

   

    States are not permitted to regulate most plans self-funded or offered by a private sector employer (group health plans) authorized by Congress under terms of the Employee Retirement Income Security Act (ERISA) with a few exceptions.

 

    While group health insurers are subject to state laws and regulations in the course of selling and conducting the insurance business, such group health coverage/claim disputes are subject to ERISA. (Illinois Insurance Facts: Understanding the Health Care Provider Complaint Process)

 

    In response to 28 year confusion with ERISA preemption of state law, the new claim regulation has clarified the nature and extent of ERISA preemption of state law [Page 70254]:

 

 

    In response to 28 year confusion with ERISA preemption of state law, the new claim regulation has clarified the nature and extent of ERISA preemption of state law [Page 70254]:

 

     "In response to these comments, the Department has added to the regulation a new paragraph (k) providing interpretive guidance on the question of the relationship of the substantive regulatory standards to State law. Subparagraph (k)(1) states that the regulatory standards should not be read to supersede State law regulating insurance (even when such State law prescribes standards for claims processes and internal review of claims) unless such State law prevents the application of a requirement of the regulation. For example, a State may have a law requiring insurers to allow oral appeals of all claims or to decide claims within shorter periods of time. These laws would not prevent the application of the regulation because plans could comply with both the regulation and the State laws.
    Subparagraph (k)(2)(i) explains that a State law regulating insurance should not be considered to prevent the application of a requirement of the regulation merely because the State law establishes a review procedure to evaluate and resolve disputes involving adverse benefit determinations under group health plans, so long as the review procedure is conducted by parties other than the insurer, the plan, the plan's fiduciaries, the employer, or any employee or agent of any of the foregoing. Subparagraph (k)(2)(ii) further explains that, in the Department's view, the types of procedures described in subparagraph (k)(2)(i) are not part of the claims procedures contemplated by section 503 of the Act, but are ``external reviews'' that are beyond the scope of the regulation. As a result, while such procedures as established by State law are not preempted by the regulation, under subparagraph (k)(2)(ii), claimants cannot be required to submit their claims to such procedures in order to be entitled to file suit under section 502(a) of the Act.\33\ There is nothing in the regulation, however, that would preclude a claimant from voluntarily submitting a claim for review pursuant to a State-provided external review process."

 

    A general rule of thumb in determining if a dispute is "related to" ERISA benefits is that if a question is relating to the "quantity" of the care (pure eligibility/coverage determination), it is an ERISA issue, while a question is relating to the "quality" of the care (pure treatment), it is a non-ERISA issue, therefore quantity = ERISA, quality = non-ERISA.

 

    In accordance with U.S. Supreme Court ruling in PEGRAM et al. v. HERDRICH, if the question involves "mixed treatment and eligibility determination", it is a non-ERISA issue, therefore "mixed quality & quantity" = non-ERISA.

 

    Most disputes involving pre-certification, medical necessity, pre-existing condition and case management are non-ERISA issues, may subject to state law and regulations.

 

    In accordance with U.S. Supreme Court Ruling in RUSH PRUDENTIAL HMO, INC. v. MORAN, "ERISA does not preempt the Illinois HMO Act.", because Illinois HMO act regulates medical necessity, mixed treatment and eligibility issue, and a law to “be specifically directed toward” the insurance industry.

 

    According to a recent DOL information letter, as to Multiple Employee Welfare Arrangements, MEWA, ERISA § 514(b)(6)(A) allows state insurance regulation of MEWAs and MEWA trusts without regard to whether they are employee benefit plans covered by Title I of ERISA.

 

    State Prompt Pay Laws Do Not Regulate or Apply to Group Health Insurance Plans in Private Sectors Because They Are ERISA Plans.

 

    ERISA Plans are regulated by ERISA regulations and clams procedures in regard to timely payment/Prompt Pay timeframe:

 

Faster decisions on initial claims - rather than 90 days (or more) under current regulation, the new rule would require decisions (in most cases) not later than:

v     72 hours for urgent care claims

v     15 days for pre-service claims

v     30 days for post-service claims

v     One 15 day extension for pre- and post-service claims

 

    Therefore in accordance with U.S. Supreme Court opinions in both PEGRAM et al. v. HERDRICH and RUSH PRUDENTIAL HMO, INC. v. MORAN, if a medical claim dispute involves ERISA fiduciary issue (pure coverage/eligibility) from an ERISA plan (self-insured or fully-insured health group plans), state laws are preempted or Department Of Insurance does not have jurisdiction over such pure coverage/eligibility dispute. If a medical claim dispute involves treatment issue or mixed treatment and coverage issues from an ERISA plan, state laws are not preempted because these decisions/disputes with ERISA plans are not ERISA fiduciary functions because "mixed treatment and eligibility" (mixed quality and quantity) is not ERISA question in the first place or the dispute does not trigger or concern ERISA jurisdiction. However it is important to note that state laws may not provide direct remedies against ERISA plans for the patients and providers, such as ordering claim payments or imposing penalties directly from the payment delays, such as prompt pay violation statutory penalty if such dispute is from an ERISA plan, rather state laws may provide administrative enforcement for noncompliance of state laws, such as utilization review, external review, registration mandates for TPA's and insurers, by insurers, TPA's and managed care organizations. Such state administrative enforcement will not directly interfere ERISA claim adjudications, but will practically resolve ERISA claim disputed medical issues, such as medical necessity as in Moran's case, as required by ERISA claim regulation [Page 70269] that an ERISA fiduciary must consult with an health-care professional [Page 70271] for medical judgment consistent with state laws. However if state laws enforced by Department of Insurance provide direct enforcement over ERISA plan coverage dispute or direct penalties or interference in ERISA benefits adjudications, such state laws will be preempted by ERISA because they are impermissible connections and non ERISA remedies. This important understanding and compliance may virtually eliminate noncompliant ERISA loopholes, ultimately solve managed care crisis for this nation in absence of Patient's Bill Of Rights.

 

    Unfortunately, presently the significance and clarification of U.S. Supreme Court rulings in Pegram and Moran cases have  not been realized and implemented by any state through Department Of Insurance. (Although Illinois argued and prevailed for Moran in Supreme Court, it failed to realize or implement Moran's ruling in its administrative enforcement over mixed treatment and eligibility/mixed quality and quantity/non ERISA fiduciary functions under its utilization review and external review state laws involving ERISA plans)

 

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)

  1. "Plans must consult with appropriate health care professionals in deciding appealed claims involving medical judgment." [70268-70269, CFR § 2560.503-1(h)(3)(iii)]

  2. "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.

 

 

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

 

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".

 

 

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

 

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

 

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

 

ERISAclaim.com - 950,000 MD's Settled With Aetna & Cigna on ERISA

 

ERISAclaim.com:  ERISA Certification Programs
for Cost-Saving & Reimbursement by Compliance

 

 

Health Care Continuation Coverage; Final Rule [Rules and Regulations] [05/26/2004] | [PDF Version]| [Notices] | [Press Release]

 

DOL Health Benefits Education Campaign [New  Seminars: IL, NY, KY]

 

DOL Launches National Education Campaign "Getting It Right-Know Your Fiduciary Responsibilities"

 

Press Release  EBSA News Release: [05/18/2004]

Seminars are scheduled for Florida, Ohio, Massachusetts and Arizona, beginning in June 2004. The program will emphasize the obligation of plan sponsors and other fiduciaries to:

  • Understand the terms of their plans;

  • Select and monitor service providers carefully;

  • Make timely contributions to fund benefits;

  • Avoid prohibited transactions; and

  • Make timely disclosures to workers and their beneficiaries and reports to the government.

Publications

Meeting Your Fiduciary Responsibilities

Understanding Retirement Plan Fees And Expenses

Selecting An Auditor For Your Employee Benefit Plan

Reporting and Disclosure Guide for Employee Benefit Plans

 

DOL + DOJ Enforcement of ERISA

 

    

 

HHS Works with ERISA (+77 Millions/4 Yrs)

 

 

 

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.

 

Both Aetna and CIGNA have agreed to settle the class-action lawsuits by 950,000 physicians and agreed to process appeals in accordance with ERISA claim regulations for both ERISA claims and non-ERISA claims, and to establish external review boards for Billing and Coding Disputes, Medical Necessity Disputes and Policy Coverage Disputes, in compliance with state external review laws, however external reviews will not be available until internal appeals/ERISA appeals are completely exhausted.

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

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


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.

 

Report of the ERISA Advisory Council's Working Group on Fiduciary Education and Training (U.S. Department of Labor, Employee Benefits Security Administration)

November 8, 2002. Excerpt: "[W]e heard from an extraordinary array of able and thoughtful individuals, some representing professional organizations and some speaking on their own behalf.... There were ... important differences in perspectives, but there was also a surprising amount of agreement on where education can help fiduciaries perform better. We strongly urge anyone interested in the issue of fiduciary education to read through the transcripts of our work group's hearings ..."

How Private Health Insurance Works: a Primer
(Henry J. Kaiser Family Foundation)
Report 

 

Excerpt: "This primer ... examines the structure and operation of private health insurance-- including the types of organizations that provide it, how managed care is delivered, and how risk pools work-- and describes how private health insurance coverage is regulated under state and federal laws. The primer explains how the current nature of private insurance relates to key issues facing federal and state policymakers."

 

EBRI Frequently Asked Questions About Benefits

 

NAIC Members Adopt Discretionary Clause Model Act

Excerpt: "Model Helps Ensure Consumer Health Insurance Claims are Subject to a Fair Review

 

PHILADELPHIA (June 9, 2002) — Members of the National Association of Insurance Commissioners (NAIC) today adopted the Discretionary Clause Model Act at the association’s Summer National Meeting here.

 

The act, which was developed by the NAIC’s ERISA Working Group, prohibits the use of discretionary clauses in health insurance contracts.

 

“Discretionary clauses are an effort to give an insurance company full and final discretion in interpreting benefits and administering an insurance contract,” said Maryland Insurance Commissioner Steve Larsen, who chairs the Health Insurance and Managed Care Committee. “This places consumers at a significant disadvantage when they are seeking to overturn the denial of benefits under an insurance policy.”...."

 

 

 

UT Admin Code R590-218. Permitted Language for Reservation of Discretion Clauses.

 

 

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

 

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

 


 

UTILIZATION REVIEW AND
BENEFIT DETERMINATION MODEL ACT  PDF file

 

 

UT Admin Code R590-203. Health Grievance Review Process and Disability Claims.   (Bulletin) (Utah Code Section 31A-22-629)

 

NAIC ERISA Working Group

ERISA Handbook 3 - 11-04 (pdf) (Word)

 

DOL Publishes Revised Guide: MEWAs Under ERISA-- a Guide to Federal and State Regulation (PDF) (U.S. Department of Labor, Pension and Welfare Benefits Administration)

 

79 pages; revised September, 2002. Excerpt: "The first part of this booklet ... focuses on what constitutes an ERISA-covered plan and the regulatory and enforcement authority of the Department of Labor over such plans. The second part ... focuses on what is and what is not a MEWA and the extent to which states are permitted to regulate MEWAs that are also ERISA-covered welfare benefit plans."

 

2004  Q&As:

Consumer Protections under ERISA and California Law Compared
 (California HealthCare Foundation)

 

Excerpt: "ERISA prevents states from directly regulating health insurance arrangements established by employers, but allows states to regulate the indemnity insurers and health plans with which employers contract.... [C]onsumer protections vary depending upon whether an employer decides to retain the risk of paying medical claims (that is, to 'self-insure' the employee plan) or to purchase group insurance from a state-licensed insurer or managed care organization."

 

Document Downloads from CHCF.ORG

ERISA and Variation in California Health Plan Consumer Protections (234K)pdf
Regulation of ERISA Plans: The Interplay of ERISA and California Law (534K)pdf

 

Department Of Insurance
Web Sites for All 50 States

 

(Peer Review)
ORDER

Final Order

S T A T E  O F  N O R T H  D A K O T A
MARKET CONDUCT
EXAMINATION
REPORT -
CHIROPRACTIC BENEFITS

NORIDIAN MUTUAL INSURANCE COMPANY
DBA BLUE CROSS BLUE SHIELD OF NORTH DAKOTA

 
North Carolina Department of Insurance: Guidance On North Carolina Law As Affected By U.S. DOL Claims Rules (March 21, 2002) (PDF)
 

New Jersey Department of Health and Senior Services Bulletin: Utilization Management Appeals Process (June 20, 2002) (PDF)

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

Excerpt:  "Context  Congress and state legislatures are considering patient bills of rights that seek to strengthen opportunities for patients to have denials of coverage reconsidered by their health plans. Little is publicly known about such appeals systems."

Managed Care and Patients' Rights  (JAMA Editorial)

Excerpt:  "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."

Survey: Americans More Worried About Healthcare Costs Than Terrorist Attacks (The Henry J. Kaiser Family Foundation)

Excerpt: "Nearly four in 10 Americans (38%) say they are very worried that the amount they pay for health care services or health insurance will increase, and a similar share (37%) is very worried that their income might not keep up with rising prices over the next six months."

 

 

 

Bureau of Justice Statistics Medical Malpractice Trials and Verdicts in Large Counties, 2001  (Acrobat file) (Press release)

 

Incidence Benefits Measures in the 2003 National Compensation Survey (U.S. Department of Labor, Bureau of Labor Statistics)

 

New Statistics for Health Insurance from the 2003 National Compensation Survey (U.S. Department of Labor, Bureau of Labor Statistics)

 

Trends In Employer-Provided Prescription-Drug Coverage (U.S. Department of Labor, Bureau of Labor Statistics)

 

Medical and Retirement Plan Coverage: Exploring the Decline in Recent Years (U.S. Department of Labor, Bureau of Labor Statistics)

 

New Benefits Data from the 2003 National Compensation Survey (U.S. Department of Labor, Bureau of Labor Statistics)

 

The 2003 National Compensation Survey: a Wealth of Benefits Data (U.S. Department of Labor, Bureau of Labor Statistics)

 

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."

 

 

 

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

 

US Code Home

CHAPTER 18--EMPLOYEE RETIREMENT INCOME SECURITY PROGRAM

 

 

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

 

 

 

Advisory Opinions
for 2002

Information Letter [08/23/02]

"Section 514(a) of Title I of ERISA generally preempts state law purporting to regulate an employee benefit plan covered under that title. There are, however, exceptions to this general preemption provision....


Accordingly, in the Department’s view, Title I of ERISA does not preclude Georgia from applying its insurance law to the IUIIW Fund as a MEWA in accordance with section 514(b)(6)(A) of ERISA, as described above.(1)"

 

ERISA & Health Claim
What Is ERISA and How Does It Affect Patient Rights?

 

"ERISA was enacted in 1974 to protect the pension and welfare benefits that employers provide their workers. It currently covers about 2.5 million health plans and 125 million workers, retirees, and dependents."

 

Strangers in the Night: Law and Medicine in the Managed Care Era
by Peter D. Jacobson

[PDF]Book Reviews: Strangers In The Night: Law And Medicine In The ...

 

[PDF] ERISA Health Plans: Key Structural Variations and their Effect on liabilty

View as HTML

 

Managed Care Technical Assistance Series - Contents for Volume 6

 

State Prompt Pay Law Does NOT Work for Private Group Health Plans

Physicians Nationwide Are Confused!!!
 

Gilbert v. Alta Health & Life Insurance Co. (11th Cir. No. 01-10829,12/27/01).

 

""Because the insurance policy covered at least one other employee of Winfield Monument Company, besides Gilbert and his wife, there is no dispute that it constituted an ERISA plan."

 

American Benefits Council

Boehner Urges DOL to Delay New Claims Procedure Regulation for Group Health Plans (PDF)

"Specifically, we are concerned about provisions in the final rule that go even further

than the patients' rights bills passed by the Congress. For example, the Department's

final rule:..."

 

 

 

NAIC News Release

 

ERISA v State Laws

 

 

 

 
Working Families' Health Insurance Coverage, 1997-2001 (Center for Studying Health System Change)
 

"Of the 189 million nonelderly people in working families in 2001, 77.5 percent, or 146 million, had employer coverage,.."

 

Survey: Employee Benefits in Private Industry (2000) (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)

 

Are more workers covered by traditional fee-for-service plans, HMOs, or PPOs?

 

Definitions of Health Insurance Plans and Other Terms (Federal Government’s Interdepartmental Committee)

 

 

 

AMA AMNews
Health plan on trial: Decisions bring responsibility
A New York lawsuit presents a major test of how health plans can be held accountable for their treatment decisions. -

 

 

2002 Employee Health Benefits Survey (Kaiser Family Foundation)

 

 

 

 

 

Peer Review

 

 

DOL Secretary Testifies to Committee About ERISA Enforcement, Compliance Assistance (U.S. Department of Labor, Pension and Welfare Benefits Administration)

 

 

Study: Health Insurance Premiums Rose More Than 30 Percent Between 1996 and 2000 (U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality)

 

 

 

 

 

ctnow.com

 Health Cost Trends Shift

"The study said managed care probably has squeezed out all the savings it can from the nation's health care system and that employers are turning to other familiar devices such as increasing premiums and co-payments to trim their costs"

 

 

Independent Medical Review Experiences in California (California HealthCare Foundation)

 

 

Health Care Issues Stymie Congress (The Hartford Courant)

 

 

 

 

Small Employers Respond to Premium Increases (Center for Studying Health System Change)

 

 

Kinder and Gentler: Physicians and Managed Care, 1997-2001 (Center for Studying Health System Change)

 

 

 

 

 

 

Employer Spending on Health Care: 1987-2000 (Employee Benefit Research Institute)

 

Office for Civil Rights - HIPAA

OCR Guidance Explaining Significant Aspects of the Privacy Rule- December 4, 2002

 

 

Health Care Spending Rose 8.7% in 2001, the Fastest Rate in 10 Years, Government Statistics Say

 

In Largest Increase in 12 Years, Health Care Spending Rose 7% in 2000 ...

 (KaiserNetwork.org)

 

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.

 

 

Employer Health Benefits: 2002 Annual Survey.(pdf)
Accessibility verified January 30, 2003
(KaiserNetwork.org)

 

 

 

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

 

 

 

California Governor, Doctors Concerned about Federal Malpractice Proposal (The Sacramento Bee via NewsAlert.com)

Excerpt: "As doctors nationwide press Congress to copy a California law that limits damages in malpractice lawsuits, many in California-- including the governor and the state medical society-- fear the federal legislation may undermine state HMO reform efforts.... Washington efforts to borrow a page from Sacramento, however, may stamp out a cornerstone of patients' rights here: the ability to sue HMOs for unlimited damages."


 

 

 

 

Text of DOL Advisory Opinion 2004-01A: Governmental Plan Definition (U.S. Department of Labor, Employee Benefits Security Administration)

 

 

Sourcebook: Covering Health Issues 2004 (Alliance for Health Reform)

 

 

 

 

 

 

DOWNLOAD ENTIRE SOURCEBOOK (pdf, 5MB)

 

2005 State Legislators' Guide to Health Insurance Solutions and Glossary (PDF) (The American Legislative Exchange Council and The Council for Affordable Health Insurance)

 

Revised November 2004 -- National Compensation Survey: Employee Benefits in U.S. Private Industry (PDF) (U.S. Department of Labor, Bureau of Labor Statistics)

 

Summary: National Compensation Survey: Employee Benefits in U.S. Private Industry, 2004 (PDF) (U.S. Bureau of Labor Statistics)

 

 

   
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