ERISAclaim.com

 

ERISA & Your Insanity
Order ] FAQ & Disclaimer ] Copyright ] New Partners ] Discussion ]
 

USHealthcareCrisis.com

 

 
Products & Services
Press Release
What's New
PPACA for CFOs
Free Webinars
Seminars
Certification Program
ERISA Appeal Dept
Health Reform Laws
Pre-Payment Review Denials
Non-PPO Checks?
Embezzlement Recovery
ERISA for Hospitals
"Overpayment" Refund
ERISA Litigation Support
ERISA or PPO
ERISA or non-ERISA Appeal?
PPO + ERISA Lawsuit
Overpayment & SIU
Prompt Pay Crisis & Rx
Medical Claim Denials
Downcoding & Bundling
Pre-existing Cond. Denial
Death of Managed Care
Healthcare Crisis Bailout
Medicare RAC Overpayment
CMS New Appeal Rules
ERISA & Your Money
ERISA & Your Insanity
On-site Education
ERISA, Who?
Rx for GM Health Crisis
Medical Device Makers
Executive Brainstorming
"Failure of Imagination"
U.S. Healthcare Crisis Rx
Employers, Insurers, TPA's
Integrated Systems
ERISA Appeal 1-2-3
ERISA Demystified
Medicare & ERISA
HSA & ERISA
ERISA Criminal Enforcement
Consulting Service
Claim Recovery
Appeal Networks
950,000 MD's & ERISA
DOL Final Rules
DOL New Guidance
Supreme Court
Court Watch
Company Info
Contact Us

 

 

 

Advertisement

 

Moukawsher & Walsh, LLC
Pension and Employee Benefit Law

Benefitlawyers.com

 
 
 
 
 
 
 
 

U.S. Healthcare Crisis Turnaround?

U.S. A.

Drs. & Hospitals Employers

$1.0 Trillion / Year

$$$ ERISA $$$

50% Savings

The Only Company with Compliant Solutions for All of You

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

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

New Federal Health Claims & Appeals Laws & Regulations

for 193 Million Americans

Effective 09-23-2010

©2010, Jin Zhou, ERISAclaim.com

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

President Obama Signing Health Bill on 03/23/2010

President Gerald R. Ford Signing ERISA on 09/02/1974

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

DOL Seal - Link to DOL Home Page

UNITED STATES

DEPARTMENT OF LABOR

(Links to DOL) ©2010, Jin Zhou, ERISAclaim.com

Patient Protection and Affordable Care Act

Statutory Laws [PDF] [PDF]

 

 

Employee Retirement Income Security Act — ERISA

Webinars, Seminars & Certification Classes for New Federal Health Claim Appeals Regulations

 

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

 

ERISAclaim.com: Seminars - 2010 Two-day Basic ERISA Appeal Seminars - Denials and Overpayment Appeals

 

ERISAclaim.com - 2010 PPACA & ERISA Claim Specialist Certification Programs in Chicago, Illinois

 

ERISAclaim.com:  Create An Appeal Department for Your Hospital or Practice (In-house, onsite ERISA Claim Specialist Certification Programs)

 

 

From Einstein to US Supreme Court

Billing & Coding Managed Care Insanity

 

 © By Jin Zhou,  ERISAclaim.com

 

02-08-2007

 

 

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.
 

 

For 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

06/21/04 

"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. 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 plan.

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.

 

Side-Bar Note: 

 

"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

 Albert Einstein Has Told Us Why We Couldn’t Get Paid By Insurance Companies 

 

Albert Einstein Quotes

“Insanity: doing the same thing over and over again and expecting different results.” --- Albert Einstein.

If 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 Einstein.

 

How could we keep doing Non-ERISA and expect getting paid correctly?

 

  1. What is the law protecting patients against managed care problems for claims with employer sponsored health plans?

  2. 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?

  3. 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;

  4. 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?

  5. ERISA claims compliance and anti-fraud and abuse prevention.

 

ERISA & Claim Denials

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 & 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."

 

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."

 

 

$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

"Each 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. If 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.
 

  1. Federal and state mandates and the patient’s benefit document take precedence over these policies.

  2. 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."

 

 

   
   Back ] Home ] Next ]

[Copyright © 2001-2009, ERISAclaim.com]    [Privacy and Security Statement]
 

ERISAclaim.com & USHealthcareCrisis.com

1260 Bamberg Court, Hanover Park, Illinois 60133

Phone (630) 736-2974 - Fax (630) 736-1439

E-mail ERISAclaim@AOL.com