New Federal Health Claims & Appeals Laws
for 193 Million Americans
Obama Signing Health Bill on
Gerald R. Ford Signing ERISA on 09/02/1974
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
DEPARTMENT OF LABOR
(Links to DOL)
©2010, Jin Zhou, ERISAclaim.com
Statutory Laws [PDF]
Employee Retirement Income Security Act — ERISA
Seminars & Certification Classes for New Federal Health Claim Appeals
- Free Webinars - New Federal Claims & Appeals Regulations, Effective
Sept. 23, 2010, for 193 Million Americans
ERISAclaim.com: Seminars - 2010 Two-day
Basic ERISA Appeal Seminars - Denials and Overpayment Appeals
ERISAclaim.com - 2010
PPACA & ERISA Claim
Specialist Certification Programs in Chicago, Illinois
ERISAclaim.com: Create An Appeal
Department for Your Hospital or Practice
(In-house, onsite ERISA Claim Specialist Certification Programs)
From Einstein to US Supreme Court
Billing & Coding Managed Care Insanity
ERISA stands for
Employee Retirement Income Security Act of 1974
ERISA is the federal law that governs the administration of employee benefit
plans and the rights of the beneficiaries under the plan.
a healthcare provider, it is extremely important to understand that 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 health care for participants or their dependents directly or
through insurance, reimbursement, or
otherwise, such as managed care HMO’s, POS, PPO’s and EPO’s as
well as traditional indemnity plans.
Most private sector health plans are covered by a federal law, 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
on policy coverage, limitation, exclusion, medical necessity and reasonable
charges. Also, those individuals who manage plans (and other fiduciaries)
must meet certain standards of conduct under the fiduciary responsibilities
specified in the law, ERISA claim regulation and Summary Plan Description (SPD).
U.S. Supreme Court Unanimous Ruling
Aetna v. Davila
"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."
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. It is so ordered."
United States Supreme Court nine justices
unanimously told us how to get our money (Claims Paid) by and from a health
If you ever want any money from an employer
sponsored health plan, ERISA completely controls your money problems and
ERISA completely supersedes your state laws.
"Causes Of Action" = Lawsuit, Appeal,
Dispute, "Pissed Off", Frustration, Dissatisfaction
"To Remedy Only The Denial Of Benefits" =
Money, Money, And Ultimately Money
"ERISA Regulated Benefit Plans" =
Employer Sponsored Health Plan In Private Sector,
Both Self-insured And
Fully-insured ("through the purchase of insurance or otherwise"), More Than 80% Of Non-Medicare Claims.
"Fall Within The Scope Of" = Being
Controlled, Governed And Regulated By
"Completely" = 100%
"Preempts" = Supersedes, Invalidates,
Takes Precedence Over
Einstein Has Told Us
Why We Couldn’t Get Paid By Insurance
Albert Einstein Quotes
“Insanity: doing the same thing over and over again and expecting
different results.” --- Albert Einstein.
you still remembered US Supreme Court ERISA & your money talk, and now
listen to Albert Einstein:
“Billing and Coding Insanity:
Doing the same thing of non-ERISA over and over again and expecting
different results of not getting denied.” --- US Supreme Court & Albert
How could we keep doing Non-ERISA and expect getting paid correctly?
What is the law
protecting patients against managed care problems for claims with employer
sponsored health plans?
Why did a US Supreme
Court unanimously rule on June 21, 2004 that ERISA governs all of your
claim denials or money problems from an employer sponsored health plan and
ERISA supersedes all of your state laws for your "denial of benefits"
(money problems) in your managed care troubles?
Federal ERISA claim regulation protects patients from all of your managed
care troubles, such as claim delays, coverage denials, "over-payment"
money back hassles,
choice of network and providers, prior-authorizations, policy "limit",
silent PPO's, "Mad HMO's", down-coding and bundling to pay only a
fraction of your claims, medical necessity problems, and all of your
managed care problems;
How to best use federal ERISA and
state laws in utilization review (UR/medical necessity review) and
external reviews to get your claim paid timely and reasonably?
ERISA claims compliance and
anti-fraud and abuse prevention.
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"
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."
$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.
Agree to terms and conditions
benefit plan defines which services are covered, which are
excluded, and which are subject to dollar caps or other limits.
Members and their providers will need to consult the member's
benefit plan to determine if there are any exclusions or other
benefit limitations applicable to this service or supply."
CIGNA - Coverage Positions/Criteria
"The terms of a participant's particular benefit
plan document [Group Service Agreement (GSA), Evidence of
Coverage, Certificate of Coverage,
Summary Plan Description (SPD) or similar plan
document] may differ significantly from the standard benefit
plans upon which these Coverage Positions are based.
these Coverage Positions are inconsistent with the terms of the
member's specific benefit plan, then the terms of the member's
specific benefit plan always control."
UnitedHealthcare Medical Policies
"By clicking "I agree," you agree to be bound by
the terms and conditions expressed below, in addition to our
Site Use Agreement.
UnitedHealthcare medical policies have been made available to
you as a general reference resource. When reading these policies
you agree that:
Our Medical Policy is not your patient's Benefit Plan.
Your patient's medical
benefits are governed and determined by a benefit document,
either a Certificate of Coverage or a
Summary Plan Description. You should not rely on
the information contained in this Web site section to determine
your patient's medical benefits.
Federal and state mandates and the patient’s
benefit document take precedence over these policies.
The patient’s benefit document lists the specific
services that have coverage limits or exclusions.
Our Medical Policy does not address every situation and
individuals should always consult their physician before making
any decisions on medical care."