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U.S. Healthcare Crisis Turnaround?

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

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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

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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

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

Are All Consultants Corrupt? (Fast Company)

 

Hearing, Senate Committee on Finance, 3-3-04

View Video "Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance
or Transcript (PDF) (KaiserNetwork.org)

 

[Ann Combs: "No, the results are not good. It’s a tragedy."]

    "In one settled case, the district court judge had to order the US Attorney’s office to open a criminal investigation, investigation based on evidence he saw in a private civil case where there was evidence of money laundering, fraud, health care fraud, wire fraud, also sorts of RICO violations, a federal judge had to order the justice department to investigate. That’s a big problem."

Mila Kofman, Georgetown University

 

Health-Care 9/11 Report of 2005

Health-care WMD

 

by Jin Zhou, 02/05/2005

© 2005, Jin Zhou, ERISAclaim.com

Unanimous US Supreme Court:

Employer-Sponsored Health-Care Is Completely Governed by ERISA laws and rules; Aetna Health Inc. v. Davila, 06/21/04

Congressional Leaders:

One Administration = One Voice = ERISA Self Enforcement only, or No Enforcement?

Health-care Terrorists?

"ERISA Advantage" bogus plans, "unlimited and frequent premium increases, and the potential for rampant fraud with little, if any, regulatory recourse" in 30 years of ERISA self enforcement.

Health-care WMD (Weapons of Mass Destruction)

"Medical Inflation,  WMD" for "ERISA Advantage" from ERISA Failure - "Failure of Imagination" Again for US Healthcare:

USA: $1.9 Trillion, 15.7% of GDP

GM:  $5.6 Billion, $1,500 Per Car

Economists: Federal deficit a bigger risk than terrorism (USA Today)

"The survey, taken between Feb. 28 and March 8, found U.S. businesses had three nearly equal concerns about longer-term risks: health care, the aging population and the federal deficit."

USA 2005:
  1. Personal Bankruptcy

  2. GM Chapter 11,

  3. National healthcare expenditure $$1,9 trillion

  4. One nation under debt

  5. GAO Report: Tax Expenditures Represent a Substantial Federal Commitment and Need to Be Reexamined (PDF) (U.S. Government Accountability Office) Abstract Highlights-PDF PDF 

White House Rx:

 $1,000 HSA personal responsibility +AHP with More "ERISA advantage" for "widespread plan insolvencies and fraud" and "A Prescription For Disaster".

2005 for Michael Moore? "John Q. ERISA Enforcement"???
Congressional conclusion 2008:

"Failure of Imagination" Again, with No One's Responsibility and Accountability.

 

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.

 

 

"Failure of Imagination" Again?

"John Q.
ERISA
Enforcement"

 

U.S. Labor Secretary Elaine L. Chao Announces Stronger Retirement, Health Benefit Security for American Workers - 121% Increase in Monetary Results Shows “Commitment to Protect Hard-Earned Benefits” Release Date: 10/21/2004

"EBSA closed 4,399 civil investigations in FY 2004. Nearly 70% of those investigations resulted in correction of violations under the Employee Retirement Income Security Act (ERISA). Criminal investigations led to the indictment of 121 individuals. In addition, EBSA received a record 474 applications to participate in its compliance assistance program to help employers and plan officials to voluntarily correct specific violations of the law."

EBSA Achieves Record $3.1 Billion in Fiscal Year 2004 Results Press Release

 

Spitzer's Latest Target (yahoo.businessweek.com)

"New York's Attorney General now has employee-benefits insurers in his sights. A federal probe could be next
... WASHINGTON, TOO? "We found that favoritism, secrecy, and conflicts rule this market, and not open competition," said Spitzer in testimony about the insurance ..."

U.S. Senate Committee on Governmental Affairs:

"Oversight Hearing on Insurance Brokerage Practices, Including Potential Conflicts of Interest and the Adequacy of the Current Regulatory Framework." Date: 11/16/04

 

ERISA Failure Syndrome

U.S. Healthcare Crisis Trilogy

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

 

ERISA
Medical Killing
ERISA
Medical Inflation
ERISA
Insurance Robbery
"Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance

Read Making a Killing

?

 

?

Bar graph showing trends in hospital charges and revenues in California from 1995-2002

 

 

 

 

?

 

?

GAO-04-312

?
 

?

American Job ExportING!

Mass layoffs up in January 2004

Weirton Steel cancels 10,000

GM: $67.5 billion in 2003

One Nation under Debt: U..S. economy threatened by aging of America

 

Healthcare Disaster at Fault Verdict Index:

U.S. Government 30%

U.S. Employers & Insurers 30%

Healthcare Providers 30%

Consumers 10%

(ERISA Failure + Managed-Care) Destroyed US Healthcare
(ERISA Failure + Managed-Care + HSA) Invite US Federal Budget Deficit & Social Security Disasters = 100X 9/11 Attacks

 

GAO: Current and Emerging Fiscal and Retirement Security Challenges, American Benefits Council/MetLife Conference, Washington, DC, on January 14, 2005

  1. Rising Health care Costs Have Many Implications (Direct)

  2. Rising Healthcare Costs Have Many Implications (Indirect)

 

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

 

 

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)

 

From 03-03-2004 to 05-10-2004 to 09-30-2004

 

Why Bogus Plans Called "ERISA Advantage"???

Because There is An Advantage of None or Little/Late Enforcement of ERISA

 

Man Sentenced to Prison in Nationwide Health Insurance Scheme (Axcess News)

Excerpt: "In pleading guilty, [John B.] Hyde admitted that he was president of ISI which operated in Novato [California]. ISI marketed and sold a health plan known as the ERISA Employee Health Benefit Plan or the ERISA Advantage. The health plan was marketed and sold to thousands of people throughout the country who believed that they were covered by a legitimate health plan."

Three people arrested for health insurance fraud

 (News-Medical.net, Tuesday, 11-May-2004)

"Three people were arrested this morning for allegedly orchestrating a scheme to defraud the customers of Employers Mutual LLC, a company that purported to provide health care coverage to more than 20,000 people across the United States, but left more than $30 million in unpaid claims for medical services when it was shut down."

 

"Deputy Attorney General James B. Comey stated: “The Department of Justice is committed to the prosecution of individuals who operate bogus health insurance schemes. These schemes victimize the employees, individuals and families who believed they had health care coverage but are left uninsured with devastating personal liability for unpaid medical claims.”
 

"One of the Department of Labor's highest priorities is to protect the benefits of workers and their families,” said Ann L. Combs, Assistant Secretary of Labor for Employee Benefits Security. “These corrupt individuals took advantage of the trust that small businesses and their workers placed in them to provide health benefits. Today's indictments demonstrate our commitment to vigorously pursue those who prey on people seeking affordable health coverage for themselves and their families and ensure that they are prosecuted to the fullest extent of the law."

Canyon Lake couple arrested after federal indictment

(North County Times)

 

U.S. Department of Justice

September 30, 2004

FORMER PRESIDENT OF INTERSTATE SERVICES
INCORPORATED PLEADS GUILTY TO HEALTH CARE FRAUD

"ERISA Advantage"

 


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

 

 

DOL + DOJ Enforcement of ERISA

 

    

 

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

 

 

 
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 New Federal Claim Regulation (Final Rule)
Benefit Claims Procedure Regulation (FAQ)
Amendments to Summary Plan Description Regulations
(Final Rule)
Patient's Rights Claims Procedure Regulation (Fact Sheet)
What You Should Know about Filing Your Health Benefits Claim

 

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.

"(q) The identity of any funding medium used for the accumulation of assets through which benefits are provided. The summary plan description shall identify any insurance company, trust fund, or any other institution, organization, or entity which maintains a fund on behalf of the plan or through which the plan is funded or benefits are provided. If a health insurance issuer, within the meaning of section 733(b)(2) of the Act, is responsible, in whole or in part, for the financing or administration of a group health plan, the summary plan description shall indicate the name and address of the issuer, whether and to what extent benefits under the plan are guaranteed under a contract or policy of insurance issued by the issuer, and the nature of any administrative services (e.g., payment of claims) provided by the issuer." 

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

 

 

What If DOL Administrative Enforcement
Didn't Work For You?

[rules to be "self-enforcing"] Policy & Leadership

[Ann Combs: "No the results are not good. It’s a tragedy."]

 

Are All Consultants Corrupt? (Fast Company)

Excerpt: "That's one possible conclusion in the wake of the Enron scandal. According to David Maister, who's been studying professional-services firms for more than 20 years, it's time to clear the air."

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

Subcommittee on Health Hearing on the Uninsured, Tuesday, March 09, 2004

 

Testimony of Greg Scandlen, Director, Center for Consumer Driven Health Care, Galen Institute

"But third-party payment is not the ultimate cause, either. Our system of third-party payment is the direct result of many decades of well-intentioned, but short-sighted and ultimately misguided state and federal policies. These policies have had far-reaching and negative consequences that were unforeseen (but not unforeseeable) when they were enacted.

 

I will deal today with  two – federal tax policy and ERISA – but these are only two of the more prominent examples. Other federal laws that have contributed to the problems we face include the Hill-Burton Act of 1946, the McCarran-Ferguson Act of 1947, price controls in the early 1970s, the HMO Act of 1973, the Health Planning Act of 1974, various aspects of Medicare and Medicaid, COBRA, HIPAA, and a range of state and federal mandates."

"Health Insurance Challenges: Buyer Beware" 3-3-04

"Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance
To view this hearing click

Hearing, Senate Committee on Finance, 3-3-04

 

GAO-04-312: “Employers and Individuals Are Vulnerable to Unauthorized or Bogus Entities Selling Health Benefits”

 

Snowe Shocked by Growth in Bogus Health Insurance Plans Targeting Desperate Small Business Owners

March 3, 2004 (Senate Committee on Small Business and Entrepreneurship)

"Snowe called operators of such fraudulent plans “masters” at playing an intricate insurance shell game. “They know how to stay one step ahead of the enforcement authorities by characterizing their operations as just beyond the reach of that authority,” Snowe said. “If a state pursues them, they will claim that they are federally regulated. If the federal government comes after them, they will say that they are a state regulated insurance company.”

 

Kaiser Family Foundation Provides Transcript of Hearing on Unregulated Health Insurance Schemes (PDF) (KaiserNetwork.org)

61 pages. Entitled 'Health Insurance Challenges: Buyer Beware,' the hearing was held by the Senate Finance Committee on March 3, 2004. Witnesses: The wife of an unauthorized health insurance plan victim; Kathryn Allen, GAO; Robert Cramer, GAO; Ann Combs, DOL; Fred Nepple, NAIC ( National Assn. of Insurance Commissioners); Jose Montemayor, TDI (Texas Department of Insurance); and Mila Kofman, Georgetown University.
 

"Ann Combs: Well, again, and I’m, our hook here is ERISA. So, we’re not the agency that enforces licenser."

 

"Ann combs: It’s a frustrating situation, it is. I don’t mean to argue with you.

Senator Thomas: I’m not going to argue either, I’m just saying you went through all the good things you’re doing but the results are not good.

Ann Combs: No the results are not good. It’s a tragedy."

 

"Senator Thomas: Ms. Kofman, do you have any other suggestions other than that in terms of resolving the problem?


Mila Kofman: Ya, I think there’s a perception out there that the justice department is not prosecuting these cases and I think there is good reason for that perception because we have not seen any criminal indictments on these current operators. So one of the suggestions I have for you is to ask the justice department why they’re not going forward with these cases. In one settled case, the district court judge had to order the US Attorney’s office to open a criminal investigation, investigation based on evidence he saw in a private civil case where there was evidence of money laundering, fraud, health care fraud, wire fraud, also sorts of RICO violations, a federal judge had to order the justice department to investigate. That’s a big problem."

Written Testimony of GAO on Health Insurance Scams (U.S. General Accounting Office)

 

EBSA News Release: Labor Department Official Testifies Before Senate Finance on Health Insurance Scams [03/03/2004]

 

Testimony of Assistant Secretary Ann L. Combs Before the Senate Finance Committee [03/03/2004]

 

 

Testimony of Fred Nepple Before the Senate Finance Committee [03/03/2004]  Chair of ERISA Working Group, National Association of Insurance, Austin, TX

 

"Types of Unauthorized Plans

All the unauthorized health plans discussed in the GAO report have two factors in common. They all offer a plan that claims to provide employee benefits subject to the Employee Retirement Income Security Act of 1974 (ERISA), and they all claim to be exempt from state insurance regulation under ERISA. Unauthorized health plans take several different forms. They typically claim to be unions, business associations, professional associations, out-of-state trusts, single-employer plans, or some combination."

Fake Insurance Leaves Millions in Bills Unpaid (MedlinePlus, nih.gov)

 

Fake Insurance Leaves Millions in Bills Unpaid (Reuters, United States - Mar 3, 2004)

"WASHINGTON (Reuters Health) - More than 15,000 employers bought 144 separate bogus health insurance plans that left an estimated 200,000 policyholders with at least $252 million in unpaid claims between 2000 and 2002, the General Accounting Office told a U.S. Senate Committee Wednesday."

 

"A key problem with catching operators of health insurance scams, testified Texas Insurance Commissioner Jose Montemayor, is that many plans manage to avoid state officials by claiming to be exempt under the Federal Employee Retirement Income Security Act, ERISA."

 

"Mila Kofman, an assistant research professor from Georgetown University, said another problem is that the U.S. Justice Department has not been active enough. "Civil actions do not stop those who engage in criminal conduct," she testified. "They change their name, move to another state and repeat the scam. What is necessary are criminal actions that result in a jail sentence," she told the committee."

 

NUMBER of bogus health insurance issuers proliferating (Los Angeles Daily News)

 

"The federal government regulates most private employer-sponsored pension and benefit plans as required by the Employee Retirement Income Security Act of 1974. But the GAO says that under ERISA, self-funded employer group health plans are not subject to state oversight, increasing the probability of illicit activity.

Flanagan said until there is more regulation and consumer education in the industry, these loopholes are likely to stir more trouble for employers and individuals seeking affordable health insurance."

 

The Illusion of Group Health Insurance: Discretionary Associations (Families USA)

18 pages issue brief. Excerpt: "This segment of the health insurance market continues to grow as people who lose their traditional employer based insurance seek low-cost alternatives that seem to promise group protections. It is also a reflection of the spotty and largely inadequate regulatory system that is supposed to oversee this sector of the market."
 

Fact Sheet: Affordable Health Care for America's Families - Whitehouse.gov (press release)

 

Bush makes fresh pitch for health care remedies, tax cuts (AP through San Francisco Chronicle)

How Does ERISA Protect You?

[Ann Combs: "No the results are not good. It’s a tragedy."]

 

In addition to Labor Department (DOL) Administrative Enforncement of ERISA, Department of Justice, through FBI, Investigates and Enforces ERISA against Any Criminal Violations:

 

"By a Memorandum of Understanding dated February 9, 1975, between the Secretary of Labor and the Attorney General, criminal matters arising under 18 U.S.C. § 1027 are investigated by the Federal Bureau of Investigation (FBI). The Memorandum permits different arrangements to be made by the Department of Justice and Department of Labor on a case-by-case basis." (Criminal Resource Manual 2435 Investigative Jurisdiction -- 18 U.S.C. 1027)

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

 

Reporting by Multiple Employer Welfare Arrangements and Certain Other Entities that Offer or Provide Coverage for Medical Care to the Employees of Two or More Employers [Rules and Regulations] [04/09/2003] | [PDF Version]

§ 2520.101–2 (b)(3): b) Definitions. As used in this section, the following definitions apply:


Administrator means--"(3) In the case of a MEWA or ECE for which an administrator is not designated and a plan sponsor cannot be identified, jointly and severally the person or persons actually responsible (whether or not so designated under the terms of the instrument under which the MEWA or ECE is operated) for the control, disposition, or management of the cash or property received by or contributed to the MEWA or ECE, irrespective of whether such control, disposition, or management is exercised directly by such person or persons or indirectly through an agent, custodian, or trustee designated by such person or persons."

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

 

Licensing of ERISA-Covered
Benefit Plan Administrator?

New York State Seal
STATE OF NEW YORK
INSURANCE DEPARTMENT
25 BEAVER STREET
NEW YORK, NEW YORK 10004

The Office of General Counsel has issued the following informal opinion on January 26, 2000, representing the position of the New York State Insurance Department.

 

Licensing of ERISA-Covered Benefit Plan Administrator

Conclusion:

"Although the plan may be exempted by the preemptive effect of ERISA from licensure as an insurer under the Insurance Law, the administrator ......"               click for more details

 

Press Releases

Department of Law
120 Broadway
New York, NY 10271
 
Department of Law
The State Capitol
Albany, NY 12224
 
 
For More Information:
(212) 416-8060
For Immediate Release 
March 30, 2004
New Report Shows HMOs Do Not Adequately Comply with State Law
 

ATTENTION RADIO NEWSROOMS:
AN AUDIO CUT IS AVAILABLE BY CONTACTING THE ATTORNEY GENERAL'S 24 HOUR TOLL-FREE NEWS LINE AT (877) 345-3466, CHOICE #1.

 
Press Release

Survey Report - (HTML Version | PDF Version)

 

"Discretionary Clause" >> "Discretionary Spending" >> "Discretionary Medical Inflation" >> "Discretionary Insurance Robbery" >> Discretionary Medical Killing >> "Discretionary Universally Uninsured"  >> "Discretionary Jurisdiction Non-enforcement"  >> U.S. Healthcare Crisis!

 

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

 

HMOs Earn $10.2 Billion in 2003, Nearly Doubling Profits, According to Weiss Ratings; Blue Cross Blue Shield Plans Report 63% Jump in Earnings (BUSINESS WIRE)--Aug. 30, 2004

 

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

 

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Department of Justice

 

Criminal Resource Manual (ERISA)

(Please click on the hyperlinks to view the official DOJ web & documents)

Department of Justice > USAM > Title 9 > Criminal Resource Manual | 2401 |

 

  1. 29 U.S.C. § 501(c) -- Embezzlement and Theft From Labor Unions in the Private Sector; 18 U.S.C. § 664 -- Embezzlement and Theft From Employee Benefit Plans in the Private Sector
     
  2. Investigative Jurisdiction -- 29 U.S.C. § 501(c) and 18 U.S.C. § 664
     
  3. Form Indictment -- Embezzlement and Theft of Labor Union Assets in the Private Sector -- (29 U.S.C. § 501(c))
     
  4. Form Indictment -- Embezzlement and Theft From an Employee Pension or Welfare Benefit Plans or a Fund Connected With Such Plans -- (18 U.S.C. § 664)
     
  5. 29 U.S.C. 501(c) Decisions
     
  6. 18 U.S.C. § 664 Decisions
     
  7. Employee Benefit Plan Kickbacks -- 18 U.S.C. § 1954
     
  8. Investigative Jurisdiction
     
  9. Bribery and Graft Affecting Employee Benefit Plans -- 18 U.S.C. § 1954
     
  10. Form Indictment -- Solicitation and Receipt of Bribery and Graft Affecting Employee Pension or Welfare Plan in the Private Sector -- (18 U.S.C. § 1954)
     
  11. Form Indictment -- Offer and Gift of Bribery and Graft Payments Affecting Employee Pension or Welfare Plan in the Private Sector -- (18 U.S.C. § 1954)
     
  12. Employee Benefit Plan Kickbacks -- (18 U.S.C. § 1954)
     
  13. Decisions Involving 18 U.S.C. § 1954
     
  14. Employee Retirement Income Security Act of 1974 (ERISA) -- 29 U.S.C.§§ 1001 et seq.
     
  15. Investigative Jurisdiction
     
  16. Failure to Perform ERISA Reporting and Disclosure -- 29 U.S.C. § 1131 (ERISA Section 501)
     
  17. Elements of Proof for 29 U.S.C. § 1131 and ERISA Obligations
     
  18. Form Indictment -- 29 U.S.C. § 1131
     
  19. Coercive or Fraudulent Interference with ERISA Rights -- 29 U.S.C. § 1141
     
  20. Form Indictment -- 29 U.S.C. § 1141
     
  21. Investigative Jurisdiction -- 29 U.S.C. § 439
     
  22. Investigative Jurisdiction -- 18 U.S.C. § 1027
     
  23. Form Indictment -- Falsification of Annual Financial Report Filed by Labor Union in the Private Sector (29 U.S.C. § 439(b))
     
  24. Form Indictment -- Falsification, Concealment or Destruction of Financial Records Required to be Kept by Labor Union in the Private Sector (29 U.S.C. § 439(c))
     
  25. Form Indictment -- False Statements and Concealment of Facts in Employee Benefit Plan Records or Reports
     
  26. Decisions Related to 18 U.S.C. § 1027

 

 

If enforced as intended by Congress, ERISA could be the best protection for employee benefits plans, Rx for US health care crisis.

 

Jin Zhou, March 2005

 
Department of Justice > USAM > Title 9 > Criminal Resource Manual
prev | next

2429 Failure to Perform ERISA Reporting and Disclosure -- 29 U.S.C. 1131 (ERISA Section 501)

Title 29 U.S.C. § 1131 states:

 

    Any person who willfully violates any provision of part 1 (Reporting and Disclosure) of this subtitle (Subtitle B-Regulatory Provisions of ERISA), or any regulation or order issued under any such provision, shall upon conviction be fined not more than $5,000 or imprisoned not more than one year, or both; except that in the case of such violation by a person not an individual, the fine imposed upon such person shall be a fine not exceeding $100,000. [The amount of the fine is governed by 18 U.S.C ?.]

 

The gravamen of offense is the willful omission to perform reporting or disclosure required by ERISA. Falsification of required ERISA documents (records, reports, and certified information) is punishable as a felony at 18 U.S.C. § 1027. See 9-136.000. Caveat: Breach of fiduciary duty in Title I of ERISA without more is not a crime.

 

 

October 1997

Criminal Resource Manual 2429

Department of Justice > USAM > Title 9 > Criminal Resource Manual
prev | next

2438 Form Indictment -- False Statements and Concealment of Facts in Employee Benefit Plan Records or Reports

(18 U.S.C. § 1027)

 

The Grand Jury Charges:

 

 

That from on or about (date) in the __________ District of ___________, in [a] document[s] required by Title I of the Employee Retirement Income Security Act of 1974 ("ERISA") to be [kept as part of the records* of][certified to the administrator** of] (name of employee welfare or pension plan) , an [employee welfare benefit plan][employee pension benefit plan], the defendant ____________ did make false statement(s) and representation(s) of fact, knowing the same to be false, and did knowingly conceal, cover up and fail to disclose facts, [the disclosure of which was required by ERISA] [which were necessary to verify, explain, clarify and check for accuracy and completeness] the (name of required report or information document) , [a report required by ERISA to be published***][information required by ERISA to be certified to the administrator], that is, (describe false entry made, facts knowingly concealed, etc.) .

 

All in violation of Title 18, United States Code, Sections 1027 and 2.

 

* See 29 U.S.C. § 1027 concerning the retention of required records.

 

** See 29 U.S.C. §§ 1023(a)(2) concerning the certification of information by insurance carriers, banks, organizations providing plan benefits or holding plan assets, and sponsoring employers and employee organizations.

 

*** See 29 U.S.C. §§ 1024(b) concerning the plan administrator's publication of annual financial reports of the plan [Form 5500 series], which are filed with the Secretary of Labor via the Internal Revenue Service, and plan descriptions.

 

 

October 1997

Criminal Resource Manual 2438

Department of Justice > USAM > Title 9 > Criminal Resource Manual
prev | next

2435 Investigative Jurisdiction -- 18 U.S.C. 1027

 

By a Memorandum of Understanding dated February 9, 1975, between the Secretary of Labor and the Attorney General, criminal matters arising under 18 U.S.C. § 1027 are investigated by the Federal Bureau of Investigation (FBI). The Memorandum permits different arrangements to be made by the Department of Justice and Department of Labor on a case-by-case basis.

 

However, effective October 12, 1984, the Department of Labor may also investigate criminal violations related to the regulation of employee pension and welfare plans which are subject to Title I of the Employee Retirement Income Security Act (29 U.S.C. §§ 1001 to 1169) without further delegation of investigative authority by the Department. See 29 U.S.C. § 1136, as amended by the Comprehensive Crime Control Act of 1984, Sec. 805; 98 Stat. 2134-35. Therefore, Department of Labor investigators now have the express statutory authority to investigate violations of 18 U.S.C. § 1027. Because the FBI and the Department of Labor have concurrent jurisdiction in these cases, each investigative agency should notify the appropriate United States Attorney's Office at the earliest possible stage of an investigation. Such investigations should be closely monitored to avoid duplication of investigative effort.

2435 Investigative Jurisdiction -- 18 U.S.C. 1027

October 1997

Criminal Resource Manual 2435

Department of Justice > USAM > Title 9 > Criminal Resource Manual
prev | next

2430 Elements of Proof for 29 U.S.C. 1131 and ERISA Obligations

 

The following materials have been prepared in part by the Labor-Management Unit of the Organized Crime and Racketeering Section (202) 514-3666 and published in Criminal Case Prosecutions Involving Employee Benefit Plans: Prosecutor's Guide (United States Department of Labor, Pension and Welfare Benefits Administration, 1994).

 

In order to establish a violation of 29 U.S.C. § 1131, the government must allege and prove the following essential elements:

 

  1. The jurisdictional entity involved is an employee benefit plan within the meaning of Title I of ERISA (29 U.S.C § 1001 et seq.)

 

  1. The violator had an obligation pursuant to ERISA.

 

Under section 1131, "any person," refers to a person who has an obligation to comply with the reporting and disclosure provisions of part I, Title I of ERISA (29 U.S.C. § 1021). Generally, the person who has such an obligation is the "administrator," who is the person specifically designated in the plan documents, or if not designated, the administrator would be the sponsoring employer or employee organization or both (plan sponsor). The terms "administrator" and "plan sponsor" are defined in section 3(16) (29 U.S.C. § 1002 (16)). Also included, are persons required to certify information, such as an insurance carrier or bank, as specified in section 103 (29 U.S.C. § 1023).

 

  1. The defendant willfully violated Title I, Part I, ERISA.

 

Section 1131 punishes anyone who "willfully violates" a statutory reporting or disclosure requirement in ERISA or regulation or order issued under those statutory provisions. In United States v. Phillips, 19 F.3d 1565 (11th Cir. 1994), aff'd sub nom. USX Corp. v. United States, 115 S.Ct. 1312 (1995), the corporate sponsor of an employee pension plan was convicted of having willfully caused the plan administrator not to furnish plan participants with a summary description of a material modification in the terms of the plan as required by ERISA, namely, changes in the rules of eligibility for pension credits due former corporate employees who had become labor representatives.

  

 

    On appeal the defendant challenged the court's instruction to the jury that it need only find that the defendant had "knowingly and intentionally committed the acts which [violated Part 1 of ERISA] and . . . were not committed accidentally or by some mistake." Id. at 1583. Rejecting the defendant's claim that the jury should have been instructed that section 1131 requires a "specific intent to do something the law forbids; that is with bad purpose to disobey or disregard the law," the court upheld the trial court's instruction that section 1131 requires only a general intent and knowledge of one's acts. In construing section 1131, the court in Phillips reasoned that the ERISA misdemeanor does not require proof of a specific intent to violate the law because the statutory defense codified at 29 U.S.C. § 1028, based on good faith compliance with Department of Labor regulations, would be redundant if "willfully" required such specific intent and would, in effect, render the "willfully" in section 1131 "meaningless surplusage." Id. at 1584.

 

    See also United States v. Tolkow, 532 F.2d 853 (2d Cir. 1976), upholding the conviction of a plan trustee for having "knowingly" failed to report required party-in-interest transactions in the plan's annual financial report under ERISA's predecessor, the Welfare and Pension Plans Disclosure Act, in violation of 18 U.S.C. § 1027. Rejecting the assertion that section 1027 required proof of a specific intent to violate the law and actual knowledge of the reporting obligations, the court in Tolkow held that the defendant need only have a reckless disregard of whether he was violating the reporting obligation by failing to make any disclosure. Id. 857-59 and cases cited therein.

 

REPORTING, DISCLOSURE, AND RECORDKEEPING OBLIGATIONS

 

DOCUMENTS REQUIRED TO BE FILED

 

Documents that an ERISA plan administrator is required to file include:

 

 

·        A plan description;
 

·        A summary plan description;
 

·        Modifications and changes to the plan; and
 

·        An annual financial report, terminal and supplementary reports as required.

 

DOCUMENTS SUBJECT TO DISCLOSURE

 

 

Documents that an ERISA plan administrator is required to disclose include:

 

·        A summary plan description;
 

·        Modifications and changes to the plan;
 

·        A summary annual report;
 

·        A statement of accrued and vested benefits;
 

·        The latest Annual Report (Form 5500 series); and
 

·        Documents under which an employee benefit plan is established or operated (i.e., plan document and any trust agreement).

 

Documents which must be disclosed on request, including a statement of accrued and vested benefits, the latest Annual Report (Form 5500), and the Plan Document.

 

 

RECORD RETENTION

 

    Section 107 (29 U.S.C. § 1027) states that:

     

    "every person subject to a requirement to file any description or report or to certify any information...shall maintain records on the matters of which disclosure is required WHICH WILL PROVIDE IN SUFFICIENT DETAIL THE NECESSARY BASIC INFORMATION AND DATA FROM WHICH THE DOCUMENTS THUS REQUIRED MAY BE VERIFIED, EXPLAINED, OR CLARIFIED, AND CHECKED FOR ACCURACY AND COMPLETENESS, AND SHALL INCLUDE VOUCHERS, WORKSHEETS, RECEIPTS, AND APPLICABLE RESOLUTIONS, and shall keep such records available for examination for a period of not less than six years after the filing date of the documents based on the information which they contain, or six years after the date on which such documents would have been filed but for an exemption..."

     

    EXEMPTIONS FROM REPORTING AND DISCLOSURE

    The following plans are exempt from ERISA's Reporting and Disclosure requirements:

    Any employee welfare plan which covers fewer than

    100 participants at the beginning of the plan year;

    Any employee pension or welfare plan whose benefits are provided solely from the general assets of the employeror employee organization maintaining the plan;


    Any employee pension or welfare plan whose benefits are provided exclusively through insurance contracts or policies issued by an insurance company, provided that any contributions made by the employees are forwarded to the insurance company within three months;

Any employee welfare plan which is an apprenticeship plan that exclusively provides apprenticeship training benefits provided:

 

    1. that the administrator files certain information with the Secretary of Labor;

 

    1. ensures that the information required to be contained in such notice to the Secretary of Labor is also disclosed to employees of employers contributing to the plan who may be eligible to enroll in any course of study sponsored or established by the plan; and

 

    1. makes the above information available to employees upon request; or

Any employee welfare benefit plan which provides for day care centers.

EXAMPLES OF VIOLATIONS

 

 

Omission or refusal to file with Labor Department annual financial reports (5500 series), plan description, summary plan description (29 U.S.C. § 1024);

 

Omission or refusal to publish summary plan descriptions to participants (29 U.S.C. § 1024);

 

Omission or refusal to furnish information concerning benefits to pension plan participants (29 U.S.C. § 1025);
 

 

or,

 

Failure to maintain records from which reports and other required documents can be verified and checked (29 U.S.C. § 1027).

 

 

October 1997

Criminal Resource Manual 2430

Department of Justice > USAM > Title 9 > Criminal Resource Manual
prev | next

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).

 

In order to establish a violation of 29 U.S.C. § 1141, the government must allege and prove the following essential elements:

1.      The jurisdictional entity involved is an employee benefit plan within the meaning of title I of ERISA (29 U.S.C. §§ 1001 et. seq.).

Employee benefit plan is defined as an employee pension benefit plan or an employee welfare benefit plan. 29 U.S.C. § 1002(1), (2), and (3).

2.     The victim is a participant or beneficiary as defined in the statute. "Participant" and "Beneficiary" are defined at 3(7) and 3(8)(29 U.S.C. § 1002).

3.      The violator can be any person who uses fraud, force, violence, or threats of force or violence.

4.     The violator restrained, coerced, or intimidated, or attempted to restrain, coerce, or intimidate, a participant or beneficiary for purposes of interfering with their protected rights.

5.      Protected rights include any right to which a participant or beneficiary is or may become entitled to under the plan, Title I of ERISA, 29 U.S.C.§ 1201 (relating to tax qualification of the plan), or the WPPDA (predecessor statute to ERISA).

6.     The violator acted WILLFULLY.

 

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.

 

 

 

October 1997

Criminal Resource Manual 2432

 

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

 

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

 

 

DOL + DOJ Enforcement of ERISA

 

    

 

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

 

 

 

 

 

 

United States Department of Health and Human Services: Leading America to Better Health, Safety and Well-Being
 

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"

 

 

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

Rx = Compliant Denial & Appeals!

Forbes.com: "Roughly one in seven Americans has no health insurance. That hurts HCA Inc. (nyse: HCA - news - people), the largest U.S. hospital chain, which last year wrote off $2.21 billion of revenue because patients couldn't pay their bills."

The American Hospital Association (AHA): "Hospitals today are faced with the challenge of managing their limited resources, while continuing to deliver the highest standard of care. According to health care experts, the cost of clinical denials to individual healthcare organizations averages $3.3 million annually. However, many hospitals do not have the resources or the expertise needed to avoid unpaid days at the end of admissions and lead the denial-appeals processes."

Payments Go Under a Microscope (washingtonpost.com) "MAMSI and CareFirst recoup overpayments to doctors by making deductions from future reimbursements. Doctors can appeal insurers' decisions. But, in the end, they usually pay up, doctors and insurers agree."

Hospital Pricing and the Uninsured, Glenn Melnick, Ph.D., "Price Gouging"
(Subcommittee on Health
Hearing on the Uninsured, Tuesday, March 09, 2004)

U.S. FILES COMPLAINT AGAINST NATIONAL ACCOUNTING FIRM UNDER FALSE CLAIMS ACT (DOJ Press Release"January 5, 2004 - PHILADELPHIA – United States Attorney Patrick L. Meehan announced today the filing of the Government's complaint against national accounting firm Ernst & Young. According to the complaint, nine hospitals paid Ernst & Young for billing advice – advice which later caused the submission of false claims to the Medicare program."

USATODAY.com - Hospitals Sock Uninsured with Much Bigger Bills

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

 

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"

 

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

What You Should Know about Filing
Your Health Benefits Claim (Claims Card)
Patient's Rights Claims Procedure Regulation (Fact Sheet)
Benefit Claims Procedure Regulation (FAQ)
New Federal Claim Regulation (Final Rule)
Amendments to Summary Plan Description Regulations (Final Rule)
   

New & Interactive From DOL
New @ elaws

Health Benefits Advisor

DOL/EBSA Organization Chart/Regional and District EBSA Offices | By Topic | By Audience | By Organization | By Location  

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

ERISA Failure, Noncompliance and Nonenforcement of ERISA SPD and Claims Procedure Rules, Is the Damaged or Missing Foam on U.S. Healthcare Wings!

HMO Crisis Is Really An ERISA Crisis!

HMO & PPO Managed Care Contracting to 
Disregard & Substitute
ERISA SPD & Claims Procedure
Is The Primary & Inevitable Cause of Medical Inflation

Costly Managed Care & Medical Malpractice Lawsuits
American Job Export!

 

ERISA Failure Damages Are Greater Than
9/11 and Pearl Harbor Tragedies Combined

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

 

(ERISA Failure + Managed-Care) Destroyed US Healthcare
(ERISA Failure + Managed-Care + HSA) Invite US Federal Budget Deficit & Social Security Disasters = 100X 9/11 Attacks

 

GAO: Current and Emerging Fiscal and Retirement Security Challenges, American Benefits Council/MetLife Conference, Washington, DC, on January 14, 2005

  1. Rising Health care Costs Have Many Implications (Direct)

  2. Rising Healthcare Costs Have Many Implications (Indirect)

 

Only practical solution is to cut the skyrocketing healthcare care costs and increase the healthcare coverage and benefits at the same time without having to go to Congress to reinvent another new "Mars Project" or "Universal Uninsured Bill of Right"  -  "John Q. ERISA Enforcement".

 

 

 

 

ERISAclaim.com

Happy
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."

 

A New Diagnosis & Prescription for
Our Nation's Health-care Crisis

 

    Contrary to the popular belief,  our nation's health-care crisis has been truly and mainly caused by the lack of understanding and failing in compliance with ERISA, the federal law regulating about 80% of health-care claims or 60% of health expenditures in the U. S. by both insurance/benefits industry and health-care providers for 28 years, through reckless and fraudulent as well as revengeful, inflationary spiral billings and claim denials that destroyed or foreclosed the hope, faith and the Law & Order for our nation in health-care quality and cost control, and the lack of meaningful and practical federal administrative enforcement of ERISA claim regulations, because this inflationary spiral skyrocketing increases in managed care claim and denial war behind ERISA shield between health insurers/ERISA plans and healthcare providers have overwhelmingly outnumbered increases in cost of living and national gross domestic products, causing annual double-digit increases in health insurance premiums and skyrocket health-care costs ($1.55 trillion in 2002, 14.9% of the U.S GDP) after every managed care strategy and model failed to contain or control health-care costs in long run despite short-term savings, while entire country has devoted more and more money in litigation, legislation and noncompliant managed care campaign, which practically have solved little or no problem.

 

    In order to resuscitate U.S. Healthcare/managed care from such a critical condition, the strategy and solution must to be a common ground acceptable to all parties involved, instead of hostile and contradictory debate of punitive damage therapy vs. the uninsured coverage in Congress. This common ground for our national health-care crisis is the ERISA Claim Regulations, applicable and existing laws and regulations on the book, originally designed by Congress in 1974 to regulate health-care claim dispute and to avoid fiduciary breach and failures we are facing today.

 

    A new practical and effective solution to saving our nation's health-care system is  to implement ERISA as Congress intended by creating a new occupation or profession, ERISA claim specialists and departments, t0 bridge the gap FROM medical billers and coders & insurance claim processors TO lawyers for both health-care providers and insurance companies/ERISA plans, and to educate everyone in  health-care and employee benefits system, health-care providers and their associations and leaders, IPA's, MCO's, health insurance, employee benefits TPA's and legislators as well as regulators to truly understand ERISA, and comply with existing ERISA's claim procedures and benefits administration rules, to make practical sense for health insurance delivered as employee welfare benefits under ERISA, protecting participants and beneficiaries and safeguarding plan assets through compliance of ERISA laws and regulations by everyone.

 

    How do we know this is the right diagnosis and prescription?

 

Plain and simple, imagine what would happen if the U.S. healthcare superhighway transported $1.55 trillion for 283 million Americans each year without an understanding, without compliance by any one and without the enforcement of any existing laws and regulations governing those 80% of the healthcare claims, 60% of the healthcare expenditures and 163 million Americans under ERISA?

 

The latest Harvard & RAND study for Congress and state legislative debate on Patients' Bills of Rights, conducted by David Studdert and Carole Roan Gresenz, study authors from the Harvard School of Public Health and RAND, funded by federal government, Department Of Labor, and Agency for Health Care Research and Quality, revealed that "little is publicly known about such appeals system", and concluded that "A majority of preservice appeals disputed choice of provider or contractual coverage issues, rather than medical necessity. Medical necessity disputes proliferate not around life-saving treatments but in areas of societal uncertainty about the legitimate boundaries of insurance coverage. Greater transparency about the coverage status of specific services, through more precise contractual language and consumer education about benefits limitations, may help to avoid a large proportion of disputes in managed care.

 

A JAMA Editorial commenting this study further supported the conclusion of this study and advanced the right solutions more precisely at New ERISA Claim Regulations: "Regulations issued by the Clinton administration in 2000 were designed to infuse rigor into the appeals process maintained by employer-sponsored health plans covered by the Employee Retirement Income Security Act (ERISA),10 which governs insurance arrangements for more than 150 million workers and their family members. Whether these rules will be vigorously enforced remains to be seen."

 

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


ERISAclaim.com has provided this nation with a turnkey operational solution with ERISA compliance, to educate everyone on ERISA, coverage and claim procedures, to ensure "Bill Of Rights" for Patients, Providers, Plan Sponsors and Insurers.


CBO projects 2.7 trillion in deficits (AP - ktvotv3.com)

 

Letter to the Honorable Ted Stevens regarding the preliminary results of CBO's analysis of the President's budgetary proposals for fiscal year 2005, CBO, February 27, 2004

 

Report: US FY03 Budget Gap Much Worse Under Accrual Accounting (Quicken - Feb 27, 2004)

"The official U.S. budget deficit, which is calculated using cash accounting, hit a record $374 billion in fiscal year 2003. That figure becomes a whopping $665 billion under the accrual method the government uses to compile its annual financial report."

Greenspan warns against deficits (CNN - Feb 25, 2004)

 

Text of Alan Greenspan's Statement to Budget Committee on Effect of Baby Boomer Retirements (U.S. House of Representatives Budget Committee)

 

HEALTH CARE SPENDING REACHES $1.6 TRILLION IN 2002 (CMS.HHS.Gov)

 

Health Spending Projections Through 2013 (Health Affairs -- Heffler Web Exclusive)

 


Benefit Spending Drives Compensation Costs (BenefitNews.com)

 

Employer Costs for Employee Compensation--December 2003 02/26/2004 (Bureau of Labor Statistics)

 

Mass layoffs up in January 2004 (Bureau of Labor Statistics)

 

 

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

Excerpt: "We were surprised to find in our latest tracking poll that more Americans are worried about health care costs than about losing their job, paying their rent or mortgage, losing money in the stock market, or being a victim of a terrorist attack.

 

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."

Problems and Priorities (pollingreport.com)

82% of Americans rank healthcare among their top issues, according to Gallup Poll.

HEALTH COSTS--The Breaking Point (FORTUNE.com)


"Worker health costs will rise a staggering 24% this year. Companies can no longer afford to pick up the bill. The battle is here."

 

"Pipal said there is little recourse for disgruntled physicians and their patients, because managed-care companies function under the Employee Retirement Income Security Act (ERISA) of 1974, a federal law with new provisions governing health care benefits."

Are All Consultants Corrupt? (Fast Company)

Excerpt: "That's one possible conclusion in the wake of the Enron scandal. According to David Maister, who's been studying professional-services firms for more than 20 years, it's time to clear the air."

Law Professor Looks at Criminal Prosecution for HMO Treatment Denial (Prof. John A. Humbach published by the Health Administration Responsibility Project (harp.org))

 

Staying Out of Jail Under ERISA's Bulked-Up Criminal Law Penalites (Attorneys Russell D. Shurtz and Craig R. Pett)

 

Excerpt:

 

"Criminal Sanctions Under ERISA Section 501

 

Maximum Criminal
Fine (Individuals)

Maximum Jail
Time

Maximum Criminal
Fine (Companies)

Before Sarbanes-Oxley

    $5,000

One Year

$100,000

After Sarbanes-Oxley

$100,000

Ten Years

$500,000"

"These are hefty increases. Few have focused on the fact that these bolstered penalties apply not only to black-out notices, but also to ERISA's other plain-vanilla reporting and disclosure requirements. The term "criminal penalties" seems so out of place with mundane things like SPDs, SARs, and other run-of-the-mill benefit plan documents."

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

 

 

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 & Claim

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 ERISA Settlemnt with 950,000 MD's

 

 

 

ERISA Laws/Rules

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

 

ERISA in US CODE

 

 

 

HHS OCR
Home Page

 

HIPAA Privacy

 

Office for Civil Rights - HIPAA

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

 

 
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,.."

 

 

 

 

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

 

 

 

Managed Care and Patients' Rights
(JAMA
Editorial)

 

 

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

 

 

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

 

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

 

 

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

 

 

 

US Department of Justice Seal

USDOJ

 Office of the Deputy Attorney General:

Publications and Documents

 

bullet The Health Care Fraud and Abuse Control Program FY 2002

 

bullet The Health Care Fraud and Abuse Control Program FY 2001

 

bullet The Health Care Fraud and Abuse Control Program FY 2000

 

bullet The Health Care Fraud and Abuse Control Program FY 1999

 

bullet The Health Care Fraud and Abuse Control Program FY 1998

 

bullet Health Care Fraud Report, Fiscal Year 1998

 

bullet Health Care Fraud Report, Fiscal Year 1997

 

USDOJ: DAG: Corporate Fraud Task Force

 

Federal Bureau of Investigation - Health Care Fraud Unit  

FBI: About the Health Care Fraud Unit

 

VideoVIDEO

 

Link to Site Map

 

Fighting Fraud & Abuse

 
bullet What is Medicare fraud?
bullet How do you recognize it? Fraud Tips
bullet How do you report it?
bullet Recent schemes and scams uncovered by Medicare (alerts)

 

Program Integrity Manual (PIM)

 

Examples of Fraudulent Activities

 pdf | word |

 

 

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

 

 

 

 

 

 

 

DOWNLOAD ENTIRE SOURCEBOOK (pdf, 5MB)

 

 

 
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