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New Federal Health Claims & Appeals Laws & Regulations

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©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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ERISA Appeal 1-2-3

A Guide from DOL with "Dummy Annotations"

 © 2004  Jin Zhou, ERISAclaim.com

In order to make ERISA understandable, as easy as 1-2-3, for dummies and no-brainers, we present the official guide from DOL, Department Of Labor, Federal ERISA Enforcement Agency, with some annotating notes, to show the basic idea and a picture of the most complicated ERISA law for 80% of US health care claims.

 

ERISA law applies to patients, healthcare providers, insurance companies and TPA's  as well as employers.

 

We received numerous comments and feedbacks on our comprehensive chapters and pages on this web site, requesting for a simplified "dummy version" ERISA page and a roadmap of the ERISA basics in health care claim appeals.

 

We would like to try this format to find out if we could accomplish this huge task. Please e-mail your questions and comments.

 

 

Medical Claim Delays & Denials? What Does an 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: "employer-sponsored group health plans" = "ERISA-regulated benefit plans", both self-insured and fully-insured (through purchase of insurance) health plans, (ERISA - Title 29, Chapter 18.  Sec. 1002.)

 

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."

 

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

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

 

What You Should Know about Filing Your Health Benefits Claim

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.

 

ERISAClaim.com Notes:  
  1. If you have health insurance (benefits) from your job in private-sector, you're covered under ERISA, Employee Retirement Income Security Act of 1974, the federal law.

  2. "Protects You": ERISA regulates and governs your insurance dispute and denial, this is true for both self-insured and fully-insured health plans (your employer bought a group insurance policy).

  3. ERISA, the federal law, requires insurance company and HMO to tell you everything (Information) and ERISA guarantees your rights and fair processing of your claims and appeal of denials.

  4. ERISA, the federal law, instead of state insurance laws, regulates your health insurance dispute and denials if you're covered from private employer sponsored health plans.

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.

 

ERISAClaim.com Notes:  
  1. Under ERISA, the insurance policy is called SPD, Summary Plan Description, ERISA version of insurance policy.

  2. Your employer or anyone in charge of the health insurance must give you a copy of SPD as required by federal law.

  3. SPD has everything about "what is covered" or  "what is not covered", including pre-existing condition, deductible, PPO, HMO, and who is legally responsible for your claim processing and dispute.

  4. Many SPD's are publicly available on Union or Company intranet or website: 1199SEIU National Benefit & Pension Funds - SPDs; US AIRWAYS SPD.

  5. If you requested for a copy of SPD and didn't receive it as specifically required by ERISA, the entity or individual responsible for this compliance will be fined for up to $110 per day by federal court.

 

Filing a Claim for Benefits

ERISA requires every plan to have procedures for filing a claim and to tell you what those procedures are. As noted above, this information must be included in the summary plan description.

All plans have rules governing what benefits they offer and how to apply for them. For example, some plans may require you to file a claim (seek authorization) before you can receive medical treatment. Some plans may have special rules for urgent care. For other plans, you must submit a claim for reimbursement after receiving and paying for the care yourself.

 

ERISAClaim.com Notes:  
  1. ERISA has rules for your health insurance and for you, it is outlined in a document, ERISA version of insurance policy, SPD.

  2. Insurance companies must follow these rules and procedures.

  3. You must also specifically follow these rules to get your claims paid, and to follow the steps outlined in SPD if your claims are denied.

  4. If you can't follow these rules, you won't get your health care or won't get claims paid from your insurance.

 

To avoid a delay in processing your claim or a denial of your claim, you should follow the steps outlined in your plan's summary plan description when filing your claim. If you cannot find the steps, or if you cannot understand them, you should consult your plan administrator or contact the Department of Labor's Employee Benefits Security Administration (EBSA) for help in understanding your rights.

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Waiting for a Decision on Your Claim

Your plan's claims procedure should state the time within which the plan must provide you with a decision on your claim. Be sure to look for these in your SPD. When you submit a claim to your plan, note the date and keep track of the time as you wait for a decision. Some plans may have different time periods depending on the nature of the benefit claim - such as if the claim is for urgent care or whether the claim is filed before medical care is received or after. Some plans' procedures allow the plan to extend the time period. Your plan's claims procedure should provide for the plan's notification to you of the plan's decision on your claim for benefits. If you do not get a response from your plan within the specified time period, contact your plan administrator.

 

 

ERISAClaim.com Notes:  
  1. ERISA has very specific rules on timelines your insurance HMO/PPO must follow after you send your claims.

  2. Different types of claims require different timeline for response.

  3. ERISA "Promt Pay" timeline can be found by clicking here and check below.

 

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What to Do If Your Claim is Denied

Your plan may deny a claim for many reasons. For example, you may not have met the plan's annual deductible, the requested treatment may be something the plan says is not covered or not medically necessary, or you may not have filed enough information for the plan administrator to process the claim. Look for the reason and other information provided in the notice of denial so that you can determine if you want to appeal the decision.

 

ERISAClaim.com Notes:  
  1. You must read carefully specific reasons your insurance company gave when you receive denials.

  2. Usually this type of denial notice is called EOB in your doctor's office, Explanation of Benefits.

  3. Only reasons given and found on this EOB, Explanation of Benefits, are official and legal grounds for denial.

  4. Any payment less than 100% claimed is considered denial, partial denial or total denial.

  5. Your denial notice is extremely important because it starts the clock ticking on your appeal rights and legal ground to appeal.

When you are notified that your claim has been denied, your plan administrator also must tell you how to appeal your denied claim for a full and fair review. Your plan will specify the number of days you have to file your appeal and may provide for extensions of that time period. When appealing a benefit denial, be sure to include any additional information or evidence supporting your claim or required by your plan's procedure, and get it to the specified person and address within the permitted time period.

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The Review of Your Appeal

Your plan's claims procedure should also specify the time period for the plan to make a decision on your appeal. Note the date when you submit your appeal and be aware of this waiting period. The waiting period for decisions on appeals may also be different depending upon the type of claim that was initially filed - such as if the claim is for urgent care or whether the claim is filed before the medical care is provided or after.

When the decision is made on your appeal, you must be notified of the decision. If your claim is denied, you must be told the reason and the plan rules upon which the decision was based in writing in a manner you can understand. If you do not receive notification of the decision within the waiting period provided for in your plan, you can assume your claim has been denied after it was reviewed.

 

ERISAClaim.com Notes:  
  1. Health insurance problems under managed-care are the most frustrating problems faced by the entire nation, but if you understand ERISA law and your plan's claims procedure in the SPD, you can win your most appeals.

  2. You must understand ERISA appeals procedure-federal law, every plan and managed-care organization must follow;

  3. you must also understand and follow your individual plan's claims procedure from that SPD.

  4. ERISA claims procedure-federal law is explained in more details by DOL by clicking here.

 

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What to Do if Your Appeal is Denied

If you disagree with the final decision on your appeal or if your plan fails to make a timely decision, you have the right under ERISA to file suit in court to get your benefits. The plan's explanation of your denial should describe this right. You also may wish to get in touch with the Department of Labor's Pension and Welfare Benefit Administration concerning your rights under ERISA.

 

 

ERISAClaim.com Notes:  
  1. If you really understand and follow ERISA laws, individual plan's claim procedure and appeal denials appropriately, you may resolve most of your dispute. Otherwise you can file lawsuit in federal court.

  2. ERISA lawsuit successful rate is mostly depending upon how well you appealed, instead of lawsuit only.

  3. Without appropriately completing your appeals as required by ERISA law and plan's appeal procedure in a timely fashion, you will most likely lose in your lawsuit in federal court.

  4. If your health insurance is in private-sector and from employment, ERISA, instead of state insurance law, is the governing Law and federal court, instead of state court, is the right place to file lawsuit.

  5. You must complete ERISA appeals before filing any lawsuit.

 

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Know Your Plan and Your Rights

As noted above, it is important that you know what your plan's claims process. If you fail to follow the plan's process, including meeting required deadlines, your ability to challenge the plan's decision in court could be affected.

If your plan's procedures do not give you the rights provided for under ERISA, or if your plan fails to follow its procedures, you may have the right to bring an action in court to enforce your rights.

For further information on your rights under ERISA, contact the Employee Benefits Security Administration's Toll-Free Employee & Employer Hotline at 1.866.444.EBSA (3272).

 

Patient's Rights Claims Procedure Regulation (Fact Sheet)

(DOL, Department of Labor)

Click the above link to DOL for basics of ERISA claim procedure and ERISA required contents of SPD (Summary Plan Description, ERISA Version of Insurance Policy)

ERISA Version of Insurance Policy; Master Copy for "Insurance Verification" Must include the Following Information:

Final Rule on Summary Plan Description

  • The final regulation updates and clarifies certain summary plan description content requirements for ERISA-covered employee benefit plans.

  • The SPD content regulation implements the information disclosure recommendations of the President’s Advisory Commission by clarifying the information required to be disclosed to plan participants and beneficiaries, in or as part of, the plan’s summary plan description, and updates the disclosure rules applicable to both pension and welfare benefit plans. The SPD content regulation:

    • Provides that health plan SPDs must describe:

      • Any cost-sharing provisions, including premiums, deductibles, coinsurance and copayment amounts for which the participant or beneficiary will be responsible

      • Any annual or lifetime caps or other limits on benefits under the plan

      • The extent to which preventive services are covered under the plan

      • Whether, and under what circumstances, existing and news drugs are covered under the plan

      • Whether, and under what circumstances, coverage is provided for medical tests, devices and procedures

      • Provisions governing the use of network providers, the composition of the provider network and whether, and under what circumstances, coverage is provided for out-of-network services

      • Any conditions or limits applicable to obtaining emergency medical care

      • Any provisions requiring preauthorization or utilization review as a condition to obtaining a benefit or service under the plan.

    • Requires that the SPDs of pension and welfare benefit plan describe, among other things, the procedures on qualified domestic relation orders (QDROs) and qualified medical child support orders (QMCSCOs), the plan sponsor’s authority to terminate the plan or eliminate benefits under the plan, COBRA continuation rights, and updated information on coverage by the Pension Benefit Guaranty Corporation and ERISA rights.

    • Repeals the limited exemption relating to SPDs of health plans that provide benefits through qualified health maintenance organizations (HMOs). Thus, health plans that provide benefits through a federally qualified HMO must comply with the improved SPD disclosure rule.

  • Adopts in final form regulations implementing amendments to ERISA made by the Newborns' and Mothers' Health Protection Act. The final regulation requires health plan SPDs to include information on requirements under federal or state law applicable to the plan, and any health insurance coverage offered under the plan, relating to hospital length of stay following newborn deliveries.

Your telephone verification always has a DISCLAIMER, but SPD can not disclaim for peace of your mind, as SPD is statutorily required to be distributed to every plan participant as a plan controlling document.

 

If you really want to know for "legally" sure, what is or isn't covered under your plan, with out "if" and "but", you should do as DOL, federal ERISA enforcement agency suggested:

 

"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."

What You Should Know about Filing (DOL)

Want to know more and get smarter on this SPD rule?

 

Amendments to Summary Plan Description Regulations (Final Rule) - New SPD Laws with more protections.

ERISA 2520.102-3 Contents of Summary Plan Ddescription. - Complete SPD laws in ERISA Regulation.

 

 

But, now you read your Plan's SPD, ERISA version of Insurance Policy, and got a lot of claim delays and denials even you did exactly as they told you on every thing, and made tons of phone calls to your state insurance department or commissioners, and insurance companies as well as so many middlemen, you were told they go by ERISA rules, not your state insurance laws. You are mad as hell and very frustrated.

 

Are they right as bad as they are to you? If you got this health insurance from work in private sectors - "ERISA protects you", still remember it?, you need to find out Rules governing your dispute, ERISA Claim Regulation.

 

Check out these rule to see if your insurance people (insurance, HMO, TPA, fiduciary and plan administrator) have followed any or none of these rules to make you so mad.

Patient's Rights Claims Procedure Regulation (Fact Sheet)

 

Faster Decisions

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:

  • 72 hours for urgent care claims

  • 15 days for pre-service claims

  • 30 days for post-service claims

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

Faster decisions on appeal of denied claims - rather than 60 days (or more) under current regulation, the new rule would require decisions (in most cases) not later than:

  • 72 hours for urgent care claims

  • 30 days for pre-service claims

  • 60 days for post-service claims

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Fairer Process

  • Claimants have more time to file appeals - 180 days, rather than current 60 days.

  • If treating physician determines the claim is “urgent,” plans must treat as urgent.

  • Plans cannot impose fees or costs as a condition to filing or appealing a claim.

  • Arbitration permitted, but only with full disclosure regarding the process, arbitrator, relationships, right to representation, and only if claimant agrees after completing internal appeal.

  • Review must be de novo.

  • Decision maker on appealed claims must be different than the person deciding initial claim.

  • Plans must consult with appropriate health care professionals in deciding appealed claims involving medical judgment.

  • Plans may not require more than two levels of review of denied claims. If more than one level, both levels must be completed within time frame applicable to one level.

  • Special rules for the continuation or extension of approved benefits or services to be provided over time (“concurrent care decisions”). Individuals receiving approved care over a period of time must have an opportunity for review before benefits are reduced or terminated. Also, urgent care requests for an extension of approved benefits must be decided within 24 hours.

  • Plans must have procedures and safeguards for ensuring and verifying consistent decision making.

  • Plans must notify claimant of defective filing of claim in case of pre-service claims.

  • If plans fail to make timely decisions or otherwise fail to comply with the regulation, claimants may go to court to enforce their rights.

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Fuller Disclosure

  • Plans must provide participants a full description of the plan’s claim procedures.

  • Plans must provide specific reasons for denials, including identification of and access to any guidelines, rules, protocols relied upon in making the adverse determination.

  • Plans must provide participants access to all documents, records and other information relevant to the benefit determination, without regard to whether the plan relied on the material.

  • Plans must disclose the name of medical professionals consulted as part of the claims process.

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Patient's Rights Claims Procedure Regulation (Fact Sheet)

 

The ERISA rule requires those people handling your insurance claims and appeals, fiduciary, to be nice and fair to you, do things fast for you and hold no secretes from you. If they followed ERISA rules, you shouldn't get mad, if not, appeal by these rules, or "If plans fail to make timely decisions or otherwise fail to comply with the regulation, claimants may go to court to enforce their rights." (what part of the laws said this?)

Now, you kind of like this ERISA rules, want to know more?

 

New Federal Claim Regulation (Final Rule) -  New Rules for Claims Dispute

 

ERISA 2560.503-1 Claims procedure  - Complete ERISA Regulation on Claims Dispute.

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.

 

You do like these lovely laws, but they are too hard for you to understand.

 

Don't worry, Uncle Sam (DOL) knew you may NOT be that smart to get these, they made these Frequently Confused/Asked Questions and Good/Smart answers, DOL FAQ, ERISA, for people like you.

 

But we think Uncle SAM is not that smart either, ERISAclaim.com and Dr. Jin Zhou, made this ERISA Time Chart and package Bundle, "ERISA Power Guides", to pack the good ERISA stuff for you to get smart on ERISA laws and rules, to go along with Uncle SAM (DOL) ERISA FAQ.

 

Oh, by the way, as mad as you are, after 143 million Americans and 950,000 doctors sued almost every insurance companies in federal court, Aetna and Cigna got smart to settle with 950,000 doctors while 143 million Americans were told by federal court to go back to get ERISA appeals or finish ERISA appeals, we got hold of these Aetna and Cigna Settlements. and surprised to learn: ERISA Settlements.

 

Benefit Claims Procedure Regulation (FAQ) (DOL)

ERISA Rules for Every One


For patients and their doctors, insurance companies, HMO, PPO and TPA's as well as employers, ERISA law applies to all of you when you deal with ERISA claims, health insurance from job in private sectors.

 

Although ERISA protects doctors, but not directly without patient's specific authorization, to name the doctor as the patient personal "authorized representative". Once the doctor/provider complied with ERISA claim procedure, you will have the same rights as your patient has under ERISA, such as getting a copy of SPD, fee schedules (UCR), reviews secretes/guidelines (DOL FAQ, B2 & B3), and right to sue in federal court, not only for medical claims, but also for SPD penalty ($110/day).

 

Benefit Claims Procedure Regulation (FAQ) (DOL)

Click above for complete official document

 

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B-2: Does an assignment of benefits by a claimant to a health care provider constitute the designation of an authorized representative?

 

No. An assignment of benefits by a claimant is generally limited to assignment of the claimant’s right to receive a benefit payment under the terms of the plan. Typically, assignments are not a grant of authority to act on a claimant’s behalf in pursuing and appealing a benefit determination under a plan. In addition, the validity of a designation of an authorized representative will depend on whether the designation has been made in accordance with the procedures established by the plan, if any.

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B-3: When a claimant has properly authorized a representative to act on his or her behalf, is the plan required to provide benefit determinations and other notifications to the authorized representative, the claimant, or both?

 

Nothing in the regulation precludes a plan from communicating with both the claimant and the claimant’s authorized representative. However, it is the view of the department that, for purposes of the claims procedure rules, when a claimant clearly designates an authorized representative to act and receive notices on his or her behalf with respect to a claim, the plan should, in the absence of a contrary direction from the claimant, direct all information and notifications to which the claimant is otherwise entitled to the representative authorized to act on the claimant’s behalf with respect to that aspect of the claim (e.g., initial determination, request for documents, appeal, etc.). In this regard, it is important that both claimants and plans understand and make clear the extent to which an authorized representative will be acting on behalf of the claimant.

 

ERISA “Prompt Pay” Time Limits

 © 2003 - 2004  Jin Zhou, ERISAclaim.com

 


ERISA §2560.503-1

Claims Procedure

 

New Rules
 Effective on 01/01/2003 for all ERISA plans

  self-insured and fully-insured, §2560.503-1(a)

Old Rules

Urgent Care Claim

Preservice Claim

Post-Service Claim

Disability Claims

ERISA Claims

Claim Beginning Time

Beginning at a Time a Claim Is Filed, Regardless of Clean Claim or Not, In Accordance With Plan Procedures, § 2560.503-1(f)(4)

Decision Maximal Time Limits

In No Event Exceeding 90 Days Period, §2560.503-1(f)

< 180 days

"Not Clean" Notification Time

24 hours

5 days

N/A

N/A

N/A

Claimant Claim Cleanup Time

48 hours

45 days

45 days

45 days

N/A

Plan Initial Determination

ASAP,
<48 hours (clean claim)
< 72 hours (cleaned up claims)

 

15 days

30 days

45 days

90 days

 

Claimant Appeal Deadline

180 days

180 days

180 days

180 days

60 days

Plan 1st Level Appeal Response Time


72 hours

15 days

30 days

45 days

60 days

Plan 2nd-Level Appeal Response Time

15 days

30 days

90 days

120 days with extensions

Plan Extension Time

48 hours

15 days

15 days

75 days

120 days

Review/Appeal Maximal Limit

72 hours

30 days (one Appeal)

15 days (two appeals)

30 days (two appeals)
60 days (one Appeal)

105 days

180 days

Initial Determination/EOB by:


"The Plan Administrator", § 2560.503-1(g)

Appeal Delay & Denial to:

"An Appropriate Named Fiduciary of the Plan", § 2560.503-1(h)

Review/Appeal Decision by:

"The Plan Administrator", § 2560.503-1(j)

 

 

For more basics of ERISA, click here to "ERISA Demystied"

 

 

For Professional Turn-key appeal Book and Systems, click here for
Appeal Book From ERISAclaim.com.

 

Free 2004 Update "ERISA Assigment Dispute" (09/16/2004)

 

Discount for March 2005: $35
 

 

$450 ERISA CD Book

Click here or the CD-Picture to enter our Secured Online Order page

Click here or the CD-Picture to enter our Secured Online Order page

 

 

You may also attend our monthly ERISA Seminars
for more hands on trainings

 

 

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

 

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

 

Aetna + CIGNA Settlement
Demystified

 © 2004  Jin Zhou, ERISAclaim.com

 

Settlements = ERISA + 3 E. B.

(Click on each hyperlinks for details)

 

"Aetna and CIGNA Settlement Secrets"

"Talking Points"

 

  1. ERISA stands for Employee Retirement Income Security Act

  2. E. B. = External Boards (of Reviews) (§7.10-7.11): 1) Medical Necessity, 2) Billing & Coding and 3) Policy Coverage

  3. Settlements Only for MCO/Provider Contract Disputes

  4. Settlements Not for Patient Coverage/ERISA Disputes, (§7.10-7.11)

  5. Patient Disputes = ERISA/Coverage/Medical Necessity/Bundling & Down Coding

  6. Provider Disputes = PPO Discount/HMO Capitation/Provider Relationship (DOL FAQ A8)

  7. Patient Disputes Provider Disputes, (DOL FAQ A8); Provider/MCO Contract (PPO/HMO) Disputes are not Triggered until Patient ERISA Disputes With the ERISA Plan Are 100% Resolved or Moot (DOL FAQ C12) (PASCACK VALLEY HOSPITAL, INC. v  LOCAL 464A UFCW WELFARE REIMBURSEMENT PLAN (3rd Cir. 11/01/2004)

  8. External Reviews (3 E. B.) Are Not Available until Internal Reviews (ERISA) Completed, (GAO)

  9. ERISA = Federal Law Mandate; External  Reviews = State Law Mandate, (GAO)

  10. No ERISA Compliance = No Rights for Any One

 

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....
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.

 

Kaiser statehealthfacts.org

 

 

 

    Due to the recent demand from the ERISA plans and TPA's, we're pleased to announce that we also provide educational and consulting services to the ERISA plans, TPA's and managed care organizations on New Federal Claim/ERISA Regulations and Compliance, however we do not provide any services involving actual claim dispute or legal advice for any legal matter or disputes.

DOL Compliance Assistance for Health Plans

 

 

 

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

 

 

New HIPAA Privacy and ERISA Claims Review Rules: 10 Reasons To Comply (Brown Rudnick Berlack Israels L.L.P.)
 

Group Health Plan Compliance with ERISA and HIPAA: Navigating the Legal and Administrative Maze (PDF) (Brown Rudnick Berlack Israels L.L.P.)

72 pages. A 'Question and Answer Resource Guide."

 

DOL

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

Excerpt: "We strongly urge anyone interested in the issue of fiduciary education to read through the transcripts of our work group's hearings ..."

 

Fact Sheet - What To Do If Your Health Coverage Can No Longer Pay Benefits

 

Questions and Answers: Recent Changes in Health Care Law (PDF)

 

Continuation of Health Coverage – COBRA

 

HIPAA Nondiscrimination Requirements Frequently Asked Questions

 

 

HHS Press Release:
 

2004.02.19: Text of Letter From Tommy G. Thompson Secretary of Health and Human Services To Richard J. Davidson, President, American Hospital Association.  

HHS FAQ "Questions On Charges For The Uninsured" (PDF)

HHS FAQ's "regarding offering discounts to the uninsured" (PDF)

 

OIG "HOSPITAL DISCOUNTS OFFERED TO PATIENTS WHO CANNOT AFFORD TO PAY THEIR HOSPITAL BILLS"


National Correct Coding Initiative Edits - Version 11
 

National Correct Coding Edits for the Hospital Outpatient PPS - Version 10.3


2003 Improper Medicare Fee-for-Service Payments Report

 

CMS Announces Revisions to Payment for Drugs and Physician Fee Schedule Payments for Calendar Year 2004

 

Medicare Announces 2004 Physician Fee Schedule and Payment Policy Changes

CMS Files for Download for Medicare Payment Systems

 

CMS Finalizes Appeals Process for Medicare Coverage Decisions

 

2003.12.10: HHS Announces Immediate Steps to Make Medicare-Approved Drug Discount Card Programs Available Next Spring

 

42 CFR Parts 403 and 408
Medicare Program; Medicare Prescription
Drug Discount Card; Interim Rule and Notice (pdf) (89 pages)

 

Revision of Billing Instructions for Purchased Services
 

Regional Offices Link


2004 Medicare Payment Information Available from CD-Rom (WPS, WI,MI,IL, MN)

 

HIPPA Final

 

 

BCBS Healthcare Cost Studies Research

BlueCard Delivers National Clients, Admin. Revenues for Blues Plans

 

NASCO Works With Blues Plans To Increase Large Local Accounts

Welcome To NASCO

 

Two Blues Giants' Enrollment Gains Show More Americans Are Turning Blue

 

Most Blue Cross Blue Shield Plans Predict Significant Managed Care Growth in 2003

 

Google Search: Bluecard program Fiduciary

 

Google Search: Bluecard program ASO

 

Google Search: Bluecard program SECURITIES AND EXCHANGE COMMISSION

 

BCBS GROUP ENROLLMENT & COVERAGE AGREEMENT

 

Aetna Reports Fourth Quarter and Full-Year 2003 Results; 2004 operating earnings guidance increased to between $6.25 and $6.3.

 

WellChoice 10K SEC

View as HTML

WellChoice 10-K Form

 

Anthem & WELLPOINT
Larry Glasscock, Chairman, President and CEO (PDF)

Investor Presentation

View as HTML

 

Summary of ANTHEM INC - Yahoo! Finance

 

Summary of WELLCHOICE INC - Yahoo! Finance

 

Blue Cross Blue Shield Plan Administrative Expenses Approximate 11% of Premiums, According to Sherlock Company

 

1199SEIU National Benefit & Pension Funds - SPDs

 

US AIRWAYS SPD

 

BWXT Y-12

Employee Book of Benefits

 

Blue Cross Blue Shield of Michigan United of Omaha Major Medical for UM

 

BCBSMT PPO Manual
View as HTML

 

BCBSMT Utilization Review

 

Card_Info

 

Medical Policy

 

BCBSTX UT SPD

View as HTML

 

BlueCard PPO BCBS

 

Blue Cross and Blue Shield System Marks 9th Consecutive Year Of Enrollment Growth (05/17/2004,Blue Cross Blue Shield Association)

 

tdi.state.tx.us

ERISA vs Non-ERISA Identification on cards (pdf)   View as HTML

 

Insurance CEOs are in the money ... AMNews: May 3, 2004.

 

Hospital CEO salaries show modest increase ... AMNews: Nov. 3, 2003.

 

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"

 

Aetna Reaches Agreement with Physicians, May 22, 2003 (Aetna.com)

 

 

Managed Care and Patients' Rights
(JAMA Editorial)

 

$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 ERISA claim 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.

 

 

 

PACIFIC COAST HOSPITAL v. AETNA HEALTHCARE

"requesting payment of benefits and/or to discuss the matter in further detail" by hospitals are wasting time and money

 

 

One Employee, One Shareholder, But ERISA Plan

(Name of the Game for 80 Percent of Health-care Claims in U.S.)

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

 

NHPF Publications  

 

NHPF Publications  

 

NHPF Publications  

 

 

2002 Employee Health Benefits Survey (Kaiser Family Foundation)

 

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)

 

 

 

 

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)

 

 

 

 

 

 

Opinion: Cutting Costs in Half Through Better Management is Fantasy But Health Care Debate Is Real (The Hartford Courant)
Excerpt: "If a talk on economics can have a $650 billion throwaway line, Treasury Secretary Paul O'Neill delivered it.... "

 

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

 

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)

 

 

 

 

 

 

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)

 

 

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

 

 

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)

 

 

 

GAO Report: Improvements to Retirement Income Data Needed (U.S. General Accounting Office)

"What GAO Recommends:

The Congress should consider directing Labor to obtain from plan administrators electronic filings of SPDs and summaries of material

modifications and make them publicly available."

 

 

 

 

 

Uninsured Reached

45 Million in 2003
US Census Press Releases

"The number of people with health insurance increased by 1.0 million to 243.3 million between 2002 and 2003, and the number without such coverage rose by 1.4 million to 45.0 million."

 

Income, Poverty, and Health Insurance Coverage in the United States: 2003 (P60-226) new
 

Health Insurance Data (Source: U.S. Census Bureau)

(10 years on the web)


Benefits cost cited in US hiring slump
Washington Times, DC - Aug 19, 2004

 

 

 

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)

 

   
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