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New Federal Health Claims & Appeals Laws & Regulations for 193 Million Americans Effective 09-23-2010 ©2010, Jin Zhou, ERISAclaim.com 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 UNITED STATES DEPARTMENT OF LABOR (Links to DOL) ©2010, Jin Zhou, ERISAclaim.com Patient Protection and Affordable Care Act Statutory Laws [PDF] [PDF]   Affordable Care Act Regulations and Guidance Interim Procedures for Federal External Review • Technical Release • Model Notice of Adverse Benefit Determination • Model Notice of Final Internal Adverse Benefit Determination • Model Notice of Final External Review Decision Interim Final Rules on Internal Claims and Appeals and External Review Processes: News Release • Regulation • Fact Sheet • NAIC Uniform External Review Model Act Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, and Patient Protections: Regulation • Fact Sheet • Patient Protection Model Notice • Lifetime Limits Model Notice • Dependents Model Notice Grandfathered Health Plans: Fact Sheet • Regulation • FAQs • Table • Model Notice Extension of Coverage For Adult Children: Fact Sheet • Regulation • FAQs • IRS Guidance FAQs on Health Care Reform and COBRA   House Committees Health Insurance Reform at a Glance: Summary • Implementation Timeline • Consumer Protections • For Employers White House Web Page on Health Reform HHS Health Reform Web Site Employee Retirement Income Security Act — ERISA ERISA Claims Procedure, 29 CFR 2560.503-1: Regulation • FAQ • Fact Sheet • Claims Guide • Claims Card Amendments to Summary Plan Description Regulations, 29 CFR 2520.102-3: Regulation • Fact Sheet • News Release • SPD Rights Fact Sheet • SPD from DOL Health Claims Related Information Consumer Information on Health Plans Compliance Assistance for Health Plans •  Fiduciary Guide Health Benefits Education Campaign Webinars, Seminars & Certification Classes for New Federal Health Claim Appeals Regulations   ERISAclaim.com - Free Webinars - New Federal Claims & Appeals Regulations, Effective Sept. 23, 2010, for 193 Million Americans   ERISAclaim.com: Seminars - 2010 Two-day Basic ERISA Appeal Seminars - Denials and Overpayment Appeals   ERISAclaim.com - 2010 PPACA & ERISA Claim Specialist Certification Programs in Chicago, Illinois   ERISAclaim.com:  Create An Appeal Department for Your Hospital or Practice (In-house, onsite ERISA Claim Specialist Certification Programs)   What is ERISA Brainstorming for Healthcare Executives? "UCR":  $5,000/day/Individual; $10,000/day/Group CALL:  1-630-736-2974 Please e-mail for more details   Maximal Healthcare Claim Reimbursement through ERISA Compliance   CMS New Appeal Rules: "Overhaul of the Medicare Claims Appeals System" Breaking News 950,000 MD's Settled With Aetna & Cigna on ERISA "Aetna and CIGNA Settlement Secrets" "Talking Points" What You Should Know about Filing Your Health Benefits Claim (DOL Claims Card) U.S. Health-care Crisis & ERISA Criminal Enforcement Are All Consultants Corrupt? (Fast Company)   ERISAclaim.com:  ERISA Certification Programs for Cost-Saving & Reimbursement by Compliance For CFO's, COOs, Denial Management Dept., Managed Care Directors,  Contract Managers, A/R Specialist, Reimbursement Manager, Office Manager, Coder's/Biller's, Patient Accounting Directors And Managers, Risk Managers, Revenue Cycle Directors, Claims/ Benefit Managers, "Provider Sponsored Organization" of HMO's, IPA's & "Integrated Health Systems/Networks" Providers, Payers And Suppliers, Employer, Insurer, TPA's, Appeals Dept., HR, and More.....   ERISAclaim.com:  ERISA Certification Programs for Cost-Saving & Reimbursement by Compliance   Conclusion or Confusion? © 2005, Jin Zhou, ERISAclaim.com   ERISAclaim.com - CMS New Appeal Rules: "Overhaul of the Medicare Claims Appeals System"   Based on our comprehensive and diligent study of this new Medicare appeal process, and our extensive experience in ERISA claim procedure practice, and "in view of the wide span of applicability of these rules and the complex, intertwined nature of the affected appeal procedures," [page 2 of 511] it is our conclusion that our nation must recognize and create a new profession, separated from and/or in addition to traditional Coding and Billing personal:   "Medicare Appeals Specialist"   Guerrilla and weekend training without systematic and quality education will definitely fail in Medicare reimbursement because of its broad requirement and "Authorized Representative" practice with "a waiver of the assignee's right to collect payment...."   "Medicare Appeals Specialist" and "ERISA Claims Specialist" will be the crown of US healthcare reimbursement.   This is why Congress and CMS created QIC (="Appeal Specialists" with dual and "sufficient medical, legal, and other expertise", § 405.968 (c) (1) [page 394 of 511]) separated FROM and in addition to Medicare Claim Processors (Medicare FI's & Carriers), (Among the major changes required by the BIPA amendments are--......Requiring the establishment of a new appeals entity, the qualified independent contractor (QIC), to conduct “reconsiderations” of contractors’ initial determinations (including redeterminations, [page 15-16 0f 511]).   And this is also why Congress enacted ERISA 30 years ago to require "an appropriate named fiduciary of the plan", § 2560.503-1(h) (1), rather than a claim processor or ASO (Administrative Services Only) TPA (Third-Party Administrator) to handle ERISA health claim appeals.   Conclusion or Confusion? Your choice and decision.   Jin Zhou, ERISAclaim.com, 03/08/2005   Medicare New Appeal & Reimbursement Seminars New Compliance & Challenges Toll-Free Numbers and Websites for Your Carrier/Fiscal Intermediary Seminar I 2 days Seminar II 2 days Seminar III 2 days New Medicare Appeal Process & Mandates v. Former Process New Medicare Appeal  Strategies for Reimbursement Success & Documentation Fraud And Abuse Medical Review National Correct Coding Initiative (NCCI) more New Medicare Appeal Laws  Intertwined with($183 million/y) ERISA Claims Laws       Unanimous US Supreme Court Ruling In US Health Care Crisis & Maximal Healthcare Claim Reimbursement by Jin Zhou, 02/11/2005 © 2005, Jin Zhou, ERISAclaim.com Managed-Care Nightmares? Maximal Healthcare Claim Reimbursement Health-Care Crisis without True Solutions?   What Does an Unanimous US Supreme Court Say?   On June 21, 2004, an unanimous US Supreme Court ruled that claim processing 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.)   How Can Anyone in USA, from Congress to General Motor to the White House, from Industry Experts to Patient Advocates, Solve US Health Care Crisis without Even Thinking of ERISA? "Failure of Imagination" As a Nation Is the Real Tragedy   ERISAclaim.com - Supreme Court Managed Care ERISA Watch   Unanimous US Supreme Court Ruling In US Health Care Crisis   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."   A Consumer Guide to Handling Disputes with Your Employer or Private Health Plan -- 2005 Update (Kaiser Family Foundation)   What You Need to Know About Your Employer-Sponsored Coverage "If you are enrolled in an employer-sponsored health plan, your right to appeal disagreements about benefits through your plan’s internal appeals process is determined by federal law (the Employee Retirement Income Security Act, or ERISA) and a federal ERISA regulation that became effective January 1, 2003."  Full Report (pdf)   USNews.com: Health: In Brief: Public Health: Winning fights with your HMO (8/12/05)         Hospital CEO's Confessed Their Biggest Headaches: Financial Challenges from Unpaid/Denied Medical Bills in 2004   71% of CEO's, out of 460 surveyed by American College of Healthcare Executives (ACHE) in 2004, identified No. 1 headache, among other things, as financial challenges. Top 5 problems of financial troubles:  Medicaid 78%, Bad Debt 72%, Medicare 70%, Revenue Cycle Management 53% and Managed-care Payments 52%. Care for the uninsured and personnel shortage were ranked as No. 2 and No. 3 pressing issues. For more details, go to ACHE's Top Issues Confronting Hospitals: 2004 Dr. Jin Zhou, President of ERISAclaim.Com, has strongly advocated for the Hospital CEO's and the entire health care industry to utilize and comply with the superpower of ERISA, federal law, governing health care denials and to create a new line of occupation, claim appeals specialist, to cope with industry claim denial crisis, soon to be tripled in 2005.   Getting paid through ERISA compliance instead of abuse and fraud. OIG: Special Advisory Bulletin: Practices of Business Consultants [PDF]  Testimony of Lewis Morris [PDF] [http://oig.hhs.gov/fraud/docs/alertsandbulletins/consultants.pdf] The Office of Inspector General (OIG), Department of Health and Human Services, June, 2001     Aetna, CIGNA CEOs Got 8-Figure Pay Packages (Connecticut Business, March 22, 2005) "Dr. John W. Rowe, Aetna's chairman and CEO, took in $22.2 million in 2004, including $18.2 million of value from exercising stock options. He also got 250,000 new stock options with a potential value of $6.1 million."   Tort Reform, Fraud & Healthcare Crisis? New From Center for Justice & Democracy:    ***New Study*** Falling Claims and Rising Premiums in the Medical Malpractice Insurance Industry (July 7, 2005) Appendix   News Release: New Study Leads Attorneys General to Proclaim “No Excuse” and “A Matter of Life and Death” (July 7, 2005) PDF   "Joanne Doroshow, Executive Director of the Center for Justice & Democracy, which commissioned the report, stated, “To put it bluntly, if you look at what the insurance companies say about why they raise premiums, and then look at the data in this report, thenumbers just don’t add up.  The facts are very simple: medical malpractice payouts are down yet insurance companies have significantly increased premiums.  This shows that the entire campaign to limit liability for doctors over the last several years by capping compensation to injured patients has been a fraud, and that based on these data, insurers must know that it has been a fraud.”   Study Backgrounder (July 7, 2005) PDF ERISAclaim.com - A $1.0 Trillion Nuclear Solution to U.S. Health-care Crisis & $44 Trillion Budget Deficits   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." Department of Justice > USAM > Title 9 > Criminal Resource Manual prev | next   ERISA in the United States Code ERISA 510 29 USC 1140 Interference with protected rights. ERISA 511 29 USC 1141 Coercive interference.   FOR IMMEDIATE RELEASE THURSDAY, DECEMBER 30, 2004 WWW.USDOJ.GOV   #807: 12-30-04 HEALTHSOUTH TO PAY UNITED STATES $325 MILLION TO RESOLVE MEDICARE FRAUD ALLEGATIONS "WASHINGTON, D.C. - HealthSouth Corporation, the nation's largest provider of rehabilitative medicine services, has agreed to pay the United States $325 million to settle allegations that the company defrauded Medicare and other federal healthcare programs, the Department of Justice announced today."   HHS-OIG-Corporate Integrity Agreements   OIG: Special Advisory Bulletin: Practices of Business Consultants [PDF] [http://oig.hhs.gov/fraud/docs/alertsandbulletins/consultants.pdf] The Office of Inspector General (OIG), Department of Health and Human Services, June, 2001     ERISAclaim.com - CMS New Appeal Rules: "Overhaul of the Medicare Claims Appeals System"   CMS News on Wheelchair and Medical Necessity December 15, 2004: MEDICARE OPENS NATIONAL COVERAGE DETERMINATION TO MAKE SURE BENEFICIARES WHO NEED WHEELCHAIRS GET THEM   October 18, 2004: MEDICARE BENEFICIARIES WILL SOON BE ABLE TO RESOLVE MEDICARE APPEALS FASTER   "Other steps that CMS is taking as part of its comprehensive overhaul of Medicare claims appeals include: Finalizing the transfer of responsibility for the third level appeals conducted by Administrative Law Judges from the Social Security Administration to the Department of Health and Human Services by October 1, 2005. Developing a new appeal-specific data system that will allow authorized users to track  individual appeals in real time. Establishing an Administrative QIC that will oversee the distribution of case-files, develop appeals processing protocols, conduct training of the QICs, and the dissemination of information on QIC appeals decisions to the public.  Implementing a 60-day decision deadline and improved notices for claims redeterminations, or first-level appeals performed by fiscal intermediaries and carriers.   The improved notices will include the specific reasons for the decision and a summary of relevant clinical or scientific evidence used in making the decision. Issuing the final regulations needed to implement the new uniform appeals procedures, including the rules QICs and other appeals entities by the end of the year."   Maximum Comfort, Inc v. Tommy G. Thompson (06/30/2004, United States District Court for the Eastern District of California)   RenCare Ltd vs. Humana Health Pln TX (5th Cir. 12/30/2004)       Money, Where??$ December 03, 2004: NEW CMS STUDY SHOWS MEDICARE, MEDICAID PAID FOR MORE THAN HALF OF ALL SENIOR HEALTH CARE   Age Estimates in the National Health Accounts (pdf), Sean P. Keehan, Helen C. Lazenby, Mark A. Zezza, and Aaron C. Catlin   National Health Accounts: Age Estimates, Personal Health Care in selected years   MEDICARE OVERPAYMENTS REACHED NEARLY $20 BILLION IN 2003, NEW SURVEY FINDS (PharmExec)   CMS ANNOUNCES IMPROVED EFFORTS TO REDUCE MEDICARE PAYMENT ERROR RATES (12/13/2004, CMS Press Release)   Meyer Medical Physic v. Health Care Service 7th Cir. 09/23/2004 "ROVNER, Circuit Judge. After Meyer Medical Physicians Group, Ltd. (“Meyer”) filed a voluntary petition for relief under Chapter 11, the bankruptcy court granted a motion by a creditor, Health Care Service Corporation d/b/a HMO Illinois (“HCSC”), to effectuate a setoff of approximately $1.3 million against amounts owed by Meyer. The district court affirmed the bankruptcy court’s discretionary decision, and Meyer appeals. We affirm." N.J. Medical Society Goes to Court To Block Recoupment of $15M in Alleged Overpayments (11/30/2004, AP via Insuarnce Journal) "The Medical Society of New Jersey is seeking court action to prevent an insurance company from recouping $15 million in alleged overpayments to doctors.   The society is seeking an injunction against Horizon Blue Cross/Blue Shield, which claims that over two years it overpaid more than 600 doctors who performed heart procedures. The insurer has asked the physicians to give back the money by Nov. 30." Doctors sue to block $15 million repayment (Newark Star Ledger, NJ - Nov 29, 2004)   Some health care costs unnecessary (APP.COM)   "In recent months, Horizon has seen a dramatic increase in the number of claims it is receiving, Marino said. New Jerseyans, he said, are receiving more health care yet, "the higher volume of services does not translate into improved quality." Health Care Analysts See Bleak Outlook for Hospitals with Reimbursement Changes (The New York Times; one-time registration required) Excerpt: "Chill is in the air for hospitals accustomed to having insurers - both public programs like Medicare and private health plans - pay ever higher prices for hospital services. That era appears to be ending, some analysts say."

"Class Actions" v. "New Strike Force"   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   ERISA Shield Explosion!!! ERISA Patient's Bill of Right from Supreme Court (Copyright © 2004 by Jin Zhou,  ERISAclaim.com) 04/28/2004 This will change entire health care and litigation landscape. Click here for more details     ERISAclaim.com provides today's health-care executives with a completely unique and unprecedented solution, through brainstorming on today's health-care crisis assessment, vital strategies to practical implementations for business bottom-line:   "New Strike Force" Medical Fraud Every Day? Appeal or Re-Bill After Denial? You Must APPEAL No Re-Billing!!! Claim Appeal or Sentencing Appeal? Your Choice Maximal Reimbursement through ERISA Appeal & Fraud Prevention and Compliance   MEDICARE OVERPAYMENTS REACHED NEARLY $20 BILLION IN 2003, NEW SURVEY FINDS (PharmExec)   CMS ANNOUNCES IMPROVED EFFORTS TO REDUCE MEDICARE PAYMENT ERROR RATES (12/13/2004, CMS Press Release)   CMA Rebuts Health Plan Allegations of Unfair Physician Billing Practices [Posted 11/11/04]  Click here to download CMA's letter to DMHC.   Blue Cross And Blue Shield Plans File $30 Million Lawsuit Alleging Rent-A-Patient Fraud In Southern California (BCBSA.com, 03/11/2005)   MAINE UROLOGIST SENTENCED FOR HEALTHCARE FRAUD (United States Department of Justice) October 6, 2004   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 Unusual provider billing practices. Discrepancy between the submitted diagnosis and the treatment. Diagnoses or treatments that are outside the practitioner’s scope of practice. Claims that are resubmitted with coding changes to gain benefits. Alterations on claim submissions. 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)  baltimoresun.com - Health plan 'stings' on rise 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."   "The National Health Care Anti-Fraud Association (NHCAA) estimates that healthcare fraud costs American consumers more than $50 billion annually. Billing for services not rendered and misrepresentation of provided services are the most common types of healthcare fraud." Task force targets health care cheats - (04/20/04, The Detroit News)  BlueCross Seeks Consumer Help in Fighting Insurance Fraud   Blue Cross and Blue Shield Association Announces New Strike Force to Protect American Consumers from Fraud and Fight Rising Costs (04/19/2004)   What are examples of common types of fraud? What are Blue Cross and Blue Shield Plans doing about healthcare fraud? What can you do if they suspect fraud? Who else investigates healthcare fraud?   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." A prosecutor accuses hospital of bribing doctors (The Wall Street Journal) "Prosecutors have filed charges against ......, accusing them of bribing doctors with "relocation agreements" in exchange for the doctors' referral of patients to the hospital. Such agreements are a well-established practice in the U.S. But now, they're under threat amid the debate over skyrocketing health-care costs.   Leading the government charge in the Alvarado case is Carol C. Lam, the U.S. attorney in San Diego. .... She filed criminal charges against Mr. Weinbaum personally, putting executives on notice that they could go to prison if their hospitals make illegal contracts." Medicare | Fraud, Abuse in Medicare and Medicaid Could Exceed Government Tracking Figures - Kaisernetwork.org   "In a statement, Sen. Larry Craig (R-Idaho), Chair of the Senate Special Committee on Aging, said, "In these tight budgetary times, it is important that every dollar that the federal government spends be well spent for its intended purpose ... But as we go after waste, fraud and abuse within Medicare, we need to make sure that we do not overreact." Health Care Now Prime Target of Federal False Claims Act (AM News)   "The reason government investigations and prosecutions are so efficient is that whistle-blowers act like bird-dogs that point out the fraud and flush it to the government attorneys," said James Moorman, president of Taxpayers Against Fraud. "Without the whistle-blowers, the federal government just can't find the fraud." "70% of False Claims Act recoveries in 2003 came from suits initiated by whistle-blowers." "Without a doubt there is still a lot of fraud to be found, but the False Claims Act is clearly changing corporate culture in the health care arena," said health economist Jack Meyer, who authored the report.   "A few years ago, health care consulting firms were advising companies about how to beat the system by cooking the books, Meyers said. Now those same consulting firms -- some of which were prosecuted under the False Claims Act for encouraging fraud -- are advising the industry on how to comply with the letter of the law and stay out of trouble, he said." "No place for fraud" "There is no place for fraud in the practice of medicine," said AMA President-elect John C. Nelson, MD. "However, it is important that as the government investigates health care fraud, there is recognition, and separation, of inadvertent errors by health care professionals from real fraud." Insurers make only small dent in medical-claims fraud (cbs.marketwatch.com) "Byron Hollis, national antifraud director for the association, said the association plans to escalate its fight against fraud and noted that the group increased its investigative staff to 500 in 2003, up 30 percent from fewer than 400 the year before."   "He noted that the association's insurers still might recover more of last year's fraudulent claim payments because some of the cases have yet to go to court." Maximum Comfort, Inc v. Tommy G. Thompson (06/30/2004, United States District Court for the Eastern District of California)   Health Care Fraud Report Fiscal Year 1998 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"   Docs Urged to Collect Fees -- Co-Payments and Deductible Payments -- Up Front (MSNBC News)   Health Care Continuation Coverage; Final Rule [Rules and Regulations] [05/26/2004] | [PDF Version]| [Notices] | [Press Release]   DOL Health Benefits Education Campaign [New  Seminars: IL, NY, KY] DOL Launches National Education Campaign "Getting It Right-Know Your Fiduciary Responsibilities" Press Release  EBSA News Release: [05/18/2004]   "Class Actions" v. "New Strike Force"   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 Medicare | Fraud, Abuse in Medicare and Medicaid Could Exceed Government Tracking Figures - Kaisernetwork.org   "In a statement, Sen. Larry Craig (R-Idaho), Chair of the Senate Special Committee on Aging, said, "In these tight budgetary times, it is important that every dollar that the federal government spends be well spent for its intended purpose ... But as we go after waste, fraud and abuse within Medicare, we need to make sure that we do not overreact." GAO: HEALTH CARE Consultants’ Billing Advice May Lead to Improperly Paid Insurance Claims, June 2001 "In summary, the two workshops about which we raise issues in this report offered in-depth discussions of regulations that pertain to billing for evaluation and management health care services2 and compliance with health care laws and regulations. During the course of discussions at those workshops, certain advice was provided that is inconsistent with guidance provided by the Department of Health and Human Services’ Office of Inspector General (OIG). Such advice could result in violations of both civil and criminal statutes. Specifically, certain consultants advocated not reporting or refunding overpayments received from insurance carriers after they were discovered. The consultants also encouraged the performance of tests and procedures that are not medically necessary to generate documentation in support of bills for evaluation and management services at a higher level of complexity than actually confronted during patients’ office visits. ...." OIG: Special Advisory Bulletin: Practices of Business Consultants [PDF]  Testimony of Lewis Morris [PDF] [http://oig.hhs.gov/fraud/docs/alertsandbulletins/consultants.pdf] The Office of Inspector General (OIG), Department of Health and Human Services, June, 2001   Health Care Now Prime Target of Federal False Claims Act (AM News) "No place for fraud" "There is no place for fraud in the practice of medicine," said AMA President-elect John C. Nelson, MD. "However, it is important that as the government investigates health care fraud, there is recognition, and separation, of inadvertent errors by health care professionals from real fraud."   Hearing: A Review of Hospital Billing and Collection Practices Subcommittee on Oversight and Investigations, June 24, 2004 Dr. Sara Collins, Senior Program Officer, The Commonwealth Fund Conclusion "......In the end, small policy changes will need to be accompanied by broad policy solutions that address the root cause of the affordability crisis in U.S. health care—policies that would expand access to affordable health insurance and reduce the rate of health care cost inflation."   Class action accuses Sutter of overcharging the uninsured Article from the Sacramento Business Journal (hospitalpricegouging.org)   CLASS ACTION LAWSUITS BY UNINSURED PATIENTS BROUGHT AGAINST SIX MORE NONPROFIT HOSPITAL SYSTEMS AROUND THE COUNTRY - 07/09/04 (hospitalpricegouging.org)   Hospital Pricing and the Uninsured, Glenn Melnick, Ph.D., "Price Gouging" (Subcommittee on Health Hearing on the Uninsured, Tuesday, March 09, 2004)   HFMA Roundtable: Emerging Roles in Revenue Cycle Leadership    HFMA Executive Roundtable: Best Practices in Revenue Cycle System Implementation   Extreme payoff: What CEOs get when they leave is a real eye-opener (American Medical News)     New Study: ER Denials? Medical or ERISA Appeals? Appeals! (Copyright © 2004 by Jin Zhou,  ERISAclaim.com) "There are two take-home messages for health professionals," Hall said. "One, insurers much less often question the appropriateness of emergency services"  = not about Medical necessity;    "and two, if insurers initially deny coverage for emergency care, providers or patients should appeal."  = ERISA Appeals   "However, some compliance problems did emerge. Some insurers, Hall told Reuters Health, initially deny ED claims and then "quickly reverse" their decision if challenged."  = always denials. "Prudent Layperson" Laws Do Not Increase Inappropriate ED Visits (Reuters via Medscape; one-time registration required) "However, some compliance problems did emerge. Some insurers, Hall told Reuters Health, initially deny ED claims and then "quickly reverse" their decision if challenged.   "There are two take-home messages for health professionals," Hall said. "One, insurers much less often question the appropriateness of emergency services and two, if insurers initially deny coverage for emergency care, providers or patients should appeal."   The impact and enforcement of prudent layperson laws (Mark A. Hall, JD, Annals of Emergency Medicine Online, May 2004 • Volume 43 • Number 5) [ABSTRACT]  [FULL TEXT] [ PDF]   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."   HCA Previews First Quarter Results "As a result, the Company's provision for doubtful accounts in the first quarter is expected to be $694 million (11.7 percent of net revenues) compared to $428 million (8.1 percent of net revenues) in the first quarter of 2003."   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."   Employers Audit Workers' Health Claims (Wall Street Journal via SFGate.com) & (MLive.com, MI) 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." USATODAY.com - Hospitals Sock Uninsured with Much Bigger Bills GM to Report $60B in Future Health-Care Obligations     ERISA Failure Syndrome U.S. Healthcare Crisis Trilogy (Copyright © 2004 by Jin Zhou,  ERISAclaim.com)   ERISA Medical Killing ERISA Medical Inflation ERISA Insurance Robbery ?   ?                         ?   ? GAO-04-312 ?   ? American Job ExportING! Mass layoffs up in January 2004 Weirton Steel cancels 10,000 GM: $67.5 billion in 2003  The Looming National Benefit Crisis (USATODAY.com) One Nation under Debt: U..S. economy threatened by aging of America NATIONAL DEBT COLLISION COURSE MEDICARE CALCULATOR METHODOLOGY ►HIDDEN COSTS ►DEMOGRAPHICS ►RISING COSTS ►YOUR SHARE ►EXPLAINOR   Healthcare Disaster at Fault Verdict Index: U.S. Government 30% U.S. Employers & Insurers 30% Healthcare Providers 30% Consumers 10%   GAO: Current and Emerging Fiscal and Retirement Security Challenges, American Benefits Council/MetLife Conference, Washington, DC, on January 14, 2005 Rising Health care Costs Have Many Implications (Direct) Rising Healthcare Costs Have Many Implications (Indirect)   Rx-1  $$$$$$$$$ERISA$$$$$$$$$$  Rx-2 Maximal Healthcare Claim Reimbursement through ERISA Compliance   What is ERISA Brainstorming for Healthcare Executives?   Federal Law, ERISA, regulates and governs approximately 80% of U.S. health-care claims and 60% of national health-care expenditures while in past two decades health-care executives are historically and practically clueless about this ERISA statutory and regulatory superpower for their business survival and development.   We also provide unique ERISA compliance brainstorming to health executives of integrated health systems, when more and more health-care provider sponsored health networks are integrating their providers and hospitals into integrated health networks as provider sponsored health plans.  No matter who administers health benefit plans, insurers or health-care providers, ERISA compliance shall be the number one priority for any integrated health system in dealing with ERISA plans, or employer-sponsored health plans in private sectors including both self-funded and fully-insured health plans.   Verispan - The True Measure of Healthcare -- Verispan Announces Release of 2004 Verispan IHN 100 IHC named nation's top health system: 2004 Versipan IHN 100 (PDF, via IHC) The latest and updated RAND/Harvard Study, funded by the U.S. Department of Labor (DOL) and requested by Congress, examines the outcomes of nearly a half-million coverage requests in two large medical groups and revealed the following:   Reasons for Denial Prospectively (RAND/Harvard Study Fund by DOL) Not a Contractually Covered Services  (Policy Exclusion) 42% Not medically necessary 29% Provider Choice (Out Of Network) 22% Other/unknown 7% "Prospective denials of coverage on grounds of medical necessity are only a small part of the overall picture." “Retrospective requests were nearly four times more likely than prospective ones were to be denied” "Denials made on contractual grounds—the largest share of denials—may call for both clinical and contractual expertise. Hence, they should ideally be made by personnel who are versant in both areas".   More than 70% of healthcare claims denied or delayed each year were Not because of coding or billing errors or disputes, but due to non-coding and non-billing related reasons, such as policy exclusion, medical necessity/utilization reviews, pre-existing exclusions, pre-certification, prior-authorization, PPO bundling and downcoding and "unknown" or unexplained reasons. Yet all denials and delays were handled by coding and billing staffs, while up to 80% of healthcare claims are ERISA claims and these coding and billing staffs have no training and knowledge in ERISA, coverage dispute, appeal procedures. No one seems to know what to do, but do whatever they felt need to be done - going circles and frustrations every day.     State of Connecticut v. Health Net, Inc., 11th Cir. 09/10/2004 State Can NOT Enforce ERISA, Publicly or Privately (ERISAclaim.com - Managed Care Court Watch)   Hawaiian Court Reverses Lower Court Ruling on ERISA Preemption of State Law on External Review (The Supreme Court of the State of Hawaii) Excerpt: "The Hawaiian Supreme Court ruled November 18, 2004, that a state law that gives Hawaii's insurance commissioner authority to conduct external reviews of health insurance plan decisions is 'impliedly' preempted by the Employee Retirement Income Security Act (ERISA)."   The Root of U. S. Healthcare Crisis Jin Zhou, ERISAclaim.com The Hearing at Senate Committee on Finance on 3-3-04, [View Video 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)     ERISA Executive Power Guides (Purified Verion) (Copyright © 2004 by Jin Zhou,  ERISAclaim.com) ERISAclaim.com - ERISA, Who?   ERISAclaim.com - ERISA 1-2-3   ERISAclaim.com - New! On-site Programs for ERISA & New CMS/Medicare Compliance   ERISAclaim.com: An Unique Magic for Integrated Health Systems   ERISAclaim.com - HSA &/Or  ERISA? 95% of HSA Are Still ERISA's!   ERISAclaim.com - CMS New Appeal Rules: "Overhaul of the Medicare Claims Appeals System"   ERISAclaim.com: ERISA Demystified for Providers, Insurers, TPAs, Patients, Regulators and Legislators   ERISAclaim.com: What's New? You Must Comply with New Federal Claim Regulations!   ERISAclaim.com - Managed Care Court Watch - Superpower & Protections for Physicians   ERISAclaim.com - 950,000 MD's Settled With Aetna & Cigna on ERISA   ERISAclaim.com: Prompt Pay Crisis & ERISA Solutions   ERISAclaim.com: How to Appeal Downcoding & Bundling Claim Denials   ERISAclaim.com: Appeals  for Commonly Seen Medical Claim Denials with Superpower from Federal & State Laws   ERISAclaim.com - "Overpayment" Refund Request & Recoupment Response & Appeals   ERISAclaim.com:  ERISA Certification Programs for Cost-Saving & Reimbursement by Compliance     ERISAclaim.com: 50% Savings - Healthcare Crisis Turnaround for Employers, Insurers & TPA's   The Latest AMA (PSA) Managed Care Hassles Survey through nationwide state medical associations and national medical specialty societies identified the most popular and important managed-care claim denials and delays.   Top Seven Issues through National Medical Specialty Societies Rank Problems Reported By Popularity Rank   % 1 Bundling 67% 2 Medical Necessity Decision Denials 43% 3 Prompt Payment 43% 4 Administrative Hassles 33% 5 Coding Issues 24% 6 Downcoding 19% 7 Bargaining Lack of Negotiation Power 14%   Top Eight Most Importantly & Frequently Listed Issues through State Medical Associations Rank Problems Reported By Importance Rank 1 Downcoding & Bundling 2 Prompt Payment 3 Lack of Budgeting Power 4 Medical Necessity Denials 5 Prior Authorization of Med. Services 6 Health Plan Credentialing 7 Drug Formularies 8 Other   Despite the worst health-care crisis since World War II, health-care executives nationwide are clueless about ERISA in governing reimbursement and denial management, or are still in denial of reimbursement crisis resulted from lack of understanding of the ERISA, even ERISA regulates and governs 80 percent of health-care claims and 60 percent of health-care expenditure for 28 years, 60-80 percent of health-care or hospital business. Knowing nothing about ERISA is the reason for executive decision not to get involved with ERISA protections, or knowing little about ERISA being good for health-care providers justified refusing to know more about ERISA.     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." Cash-poor UCLA hospitals hire turnaround firm  (Los Angeles Times) "The largest medical system in the UC chain, UCLA Healthcare reported lower net income than its sister campuses last fiscal year and as of Dec. 31 had only $20,000 cash. By comparison, UC Davis had $183 million in cash, the most systemwide." Cuts Urged for UCLA Health Staff (LATIMES.com) "The Hunter Group, a consulting firm paid $1.9 million by UCLA to suggest reforms, also said billing practices need revamping. They are so haphazard that the system billed 300 different amounts for the same procedure."  Paperwork pileup  (The Boston Globe) ''There is no innate trust in the transaction like there is in other industries,'' said James Heffernan, chief financial officer for the Mass. General physicians' group. As a result, he said, much of the money being poured into medical premiums ''isn't going into patient care.''   "We, for better or worse, are buying more administration,'' Pauly said. ''We end up spending a lot, and in the end nobody's better off.'' He suggested, ''The best thing would be if they can somehow agree to a disarmament. But so far, nobody's found a way to do that.'' (The Boston Globe) 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." 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." Doctors leave managed-care hassles behind Maine practices joining national trend in cutting insurance ties (Central Maine Daily Sentinel) "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." Subcommittee on Health Hearing on the Uninsured, Tuesday, March 09, 2004   Hospital Pricing and the Uninsured, Glenn Melnick, Ph.D., Director, Center for Health Financing, Policy and Management, University of Southern California, School of Policy, Planning and Development, Los Angeles, California   USATODAY.com - Hospital bills spin out of control "The debate over hospital charges is part of the fallout from the rise of managed care, when insurers drove down payments to doctors and hospitals with a take-it-or-leave-it attitude. In response, hospitals banded together in systems, giving them larger market share and bargaining power. Many hospitals successfully demanded bigger payments by telling insurers to pay up or they would stop accepting their patients."   "We raised charges 45%," Callanan says. "We only collected $8 million more." The Cost of Care for the Uninsured: What Do We Spend, Who Pays, and What Would Full Coverage Add to Medical Spending? (Kaiser Commission on Medicaid and the Uninsured) Issue Brief (.pdf) News Release (.pdf) "This issue update finds that uninsured Americans could incur nearly $41 billion in uncompensated health care treatment in 2004, with federal, state and local governments paying as much as 85 percent of the care. It also finds that if the country provided coverage to all the uninsured, the cost of additional medical care provided to the newly insured would be $48 billion." 82M U.S. Residents Uninsured at Some Point Over Last Two Years, Study Says - Kaisernetwork.org   One in Three: Non-Elderly Americans Without Health Insurance, 2002-2003 (Families USA)   Doctored Books (motherjones.com) "Richard Scruggs sued Big Tobacco and won. Now, he's taking on some of the nation's biggest non-profit hospital chains on behalf of the uninsured." Nonprofit Hospitals Said to Overcharge Uninsured (The New York Times) "A group of plaintiffs' lawyers filed civil lawsuits against more than a dozen nonprofit hospitals across the country yesterday, contending that the hospitals violated their obligation as charities by overcharging people without insurance and then hounding them for the money."   A common sense question without executive intelligence: if ERISA regulates 60-80 percent of your health-care business revenue, why don't we want to know more about ERISA?   Any traditional and conventional appeals without ERISA COMPLIANCE are "squeaky wheel appeals" for any ERISA claim denials and delays, 80 percent of U.S. Healthcare claims and 60% of U.S. Healthcare expenditure.   ERISA Power Guides (Copyright © 2004 by Jin Zhou,  ERISAclaim.com) What You Should Know about Filing Your Health Benefits Claim (Claims Card) Filing A Claim For Your Health Or Disability Benefits (PDF) 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 DOL/EBSA Organization Chart/Regional and District EBSA Offices | By Topic | By Audience | By Organization | By Location     State Insurance Department in All 50 States   Health Benefits Laws By State (Interactive Tools From Insure.com) Health Insurance Mandates in the States, 2004: a State-by-State Breakdown ... (PDF) (Council for Affordable Health Insurance) Kaiser statehealthfacts.org Consumer Guides for Health Insurance in Every State and the District of Columbia (Georgetown University) View a 5-minute clip Paper Chase ERISAclaim.com - U.S. Health-care Crisis & ERISA Criminal Enforcement To Avoid "John Q. ERISA Enforcement"   ERISAclaim.com: What's New? You Must Comply with New Federal Claim Regulations!   New York State, Insurance Department ISSUED 4/13/2004 FOR IMMEDIATE RELEASE Health Net To Refund $4.99 Million To Policyholders And Re-Evaluate Some Healthcare Claims  (The full report, pdf) Also Paid $500,000 Fine And Instituted Remedial Actions Under Separate Department Action   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 HEALTH PLANS FAIL TO DISCLOSE REQUIRED COVERAGE INFORMATION 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.     State of New York Office of the Attorney General Health Care Bureau   New York Managed Care Consumer Bill of Rights Compliance Survey: The Failure of New York HMOs To Provide Important Coverage Information To Consumers   Eliot Spitzer Attorney General | Printable PDF Version | Press Release Survey Report - (HTML Version | PDF Version)     ERISAclaim.com:  ERISA Certification Programs for Cost-Saving & Reimbursement by Compliance   Only appeals with full ERISA compliance will ensure maximum reimbursement or crisis turnaround at minimum cost and frustrations.   Coding and billing are less than half of the successful reimbursement practice, coding and billing are not appealing and coverage dispute practice. Many coders and billers are wonderful, non-confrontational and very sophisticated individuals, but they might be terrible and counterproductive debaters, and less than ideal legal reasoning and logical thinkers. Many financial executives are hands-free managers in reimbursement divisions.   A striking parallel phenomena is also true in the insurance and benefits industry, as described above for medical coding and billing personnel. With the industry compliance tips for the insurance/benefits industry, offered through AAHP in complying with new federal claim regulation, reflected the same problems but provided no practical solutions, the industry is strategically revising the rules of claim processors: "We're taking the claims processors out of the loop. They're good at what they do, but they definitely aren't lawyers. We don't necessarily want them to be making discretionary decisions", said James L. Touse, vice president and associate general counsel for BlueCross BlueShield of Tennessee, at a 2002 policy conference sponsored by the American Association of Health Plans.   Employer Health Plan Nightmares ... and Other Things That Go Bump in the Night (Chang Ruthenberg & Long PC) Excerpt: "Nightmare #1: The Phantom SPD For insured welfare plans, including most health insurance arrangements, the insurance company generally provides a booklet describing available benefits and limitations, cards for your employees, and a formal contract or policy that is signed by the employer. Many employers hand out the benefit booklets to eligible employees, but they do nothing further....."   That is why, starting January 1, 2003, Aetna and many other insurance companies/ERISA plans have come up with a brand-new programs,  Appeals Administration Services program, parallel to our certification program, in response to this new ERISA Storm, Real Protections for Health-care Providers and Patients, while health-care providers nationwide are still in sleeping mode pursuing moon project of protections through recycling, reinventing and salvaging the ERISA storm and protection as a result of 28 year ERISA health-care crisis and refinery process.     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."   "......In this environment, contractual coverage and medical-necessity issues that persist are likely to be for services that enrollees feel especially strongly about. Such consumer concerns, together with ongoing consumer protection agendas that include reforms such as guaranteed external review and right-to-sue provisions, mean that the policy importance of UR denials in managed care is unlikely to wane in the foreseeable future."     The updated Harvard & RAND study, funded by the U.S. Department of Labor (DOL), published on June 18, 2003 through Health Affairs, examined the outcomes of nearly a half-million coverage requests in two large medical groups that contract with health plans to deliver care and conduct utilization review, and discovered the urgency and necessity of expertise of ERISA claim procedure specialists. The study concludes the following in its summary and policy implications: "....We found much higher denial rates than those previously reported.....Denials made on contractual grounds—the largest share of denials—may call for both clinical and contractual expertise. Hence, they should ideally be made by personnel who are versant in both areas. There was some evidence of this sort of dual expertise being brought to bear on coverage decisions at the two groups we studied."   However these best experts "hired" by Congress and federal government are one step away from the complete discovery and solution. Let us fill in the missing links and connect dots in order to save our health-care system from collapsing and crisis. First, we identify the controlling force and power in contractual policy coverage denial. The majority of Americans are covered under the employer-sponsored health-care programs in private sectors under ERISA, 80% of the claims and 60% of health expenditures are regulated under ERISA. Each individual ERISA plan offers different coverage and benefits, either self-insured or fully-insured through purchase of insurance from an insurance company. The controlling and governing document for each ERISA plan is Summary Plan Description (SPD), the rule of the game for interpreting each SPD and resolving the disputes on contractual denials is ERISA claims procedure regulations. Therefore the experts from Harvard & Rand study group discovered the importance and necessity of "contractual expertise" but aborted the solution of "contractual expertise" due to "the reasons of size or financial stress, this may be beyond the reach of smaller medical groups that have assumed responsibility for UR".   Financial burden and unavailability of this contractual expertise could be the final resolution to their study group to determine if those contractual denials were made by the plan or TPA correctly. Clinical knowledge and expertise from those medical groups are inherited, but "contractual expertise" is missing badly for policy coverage, Summary Plan Description (SPD) and ERISA Claims Procedure for 80% of health care claims, because such ERISA contractual expertise is nowhere to be found, even for those very experienced health care attorneys and insurance coverage experts, as state law governed insurance policy dispute resolution and ERISA governed claims procedure dispute resolution are quite different, and entire country has never put ERISA into health-care practice. This is why our health-care system failed.   Another 2004 new Rand/Harvard study published on February 2004 issue of Annals of Emergency Medicine, "Disputes over coverage of emergency department services: A study of two health maintenance organizations" discovered that 90% of denial in utilization reviews were overturned on appeals, from a stratified random sample of approximately 3,500 appeals of coverage denials lodged by privately insured enrollees between 1998 and 2000 at 2 of the nation's largest HMOs. This study concludes: "The prevalence of ED cases among all appeals reflects disagreement between lay and expert judgments about what constitutes emergency care under the prudent layperson standard. The high rate at which enrollees win these appeals highlights significant disagreement in interpretation of the standard among different adjudicators within managed care organizations (medical groups and health plans). When enrollees fail to challenge denials that would be reversed on appeal, they bear the financial brunt of ambiguities in interpretation of the prudent layperson standard."   Who Can Be a Medical Reviewer under ERISA? (Copyright © 2004 by Jin Zhou,  ERISAclaim.com) U.S. SUPREME COURT Docket for 03-83  ORAL ARGUMENT TRANSCRIPTS (page 46 0f 49)   02-1845. Aetna Health Inc. v. Davila 03/23/04 "QUESTION: Mr. Estrada, you can address what you would like but there are three points that have come up during the Respondent's presentation that I'd be interested with a response to.   Number one, is it true that the people who make the decisions for your client must be medical doctors in Texas?   MR. ESTRADA: Well it is true by virtue of DOL regulations which provide that no claim may be turned down without input from a medical professional in the relevant area" New Federal Claim Regulation (Final Rule) "Plans must consult with appropriate health care professionals in deciding appealed claims involving medical judgment." [70268-70269, CFR § 2560.503-1(h)(3)(iii)] "The term `health care professional' means a physician or other health care professional licensed, accredited, or certified to perform specified health services consistent with State law." [page 70271 CFR § 2560.503-1(m)(7)]     "medical doctors in Texas" = MD licensed to practice medicine in Texas for a Texas ERISA case; "a medical professional in the relevant area" = relevant area of state laws in license jurisdiction, scope of practice and relevant local standard of care; "licensed" = licensed by the State Government/licensing board; "to perform" = to practice medicine or health care services in the State; "specified health services" = medical procedures or services being reviewed or denied, instead of file review or insurance coverage reviews services; "consistent with State law" = consistent with State laws where  the health care professional is legally licensed to practice medicine or health care services with respect to state jurisdictions,  scope of license and state local medical standard of care.   "The term `health care professional' means, in layman term,  a physician or other health care professional who is at least licensed in your state (and more, board certified too) to practice the specified/specific health services being reviewed or denied of your claims, consistent with your state law jurisdiction, scope of practice and local medical standard of care. Someone who is not licensed to practice the same health care services specified/denied in your claims is not qualified as an "appropriate health care professionals" as defined under ERISA § 2560.503-1(m)(7).   Someone who is not licensed in your state to practice "specified health services" but who is merely registered under state or other means (URAC, IME, SSD or Peer Reviews) to do Utilization Reviews (UR) is not qualified as an "appropriate health care professionals" as defined under ERISA § 2560.503-1(m)(7).       U.S. Supreme Court visited ERISAclaim.com in regard to ERISA § 2560.503-1(h) at 11:57:03 AM on Friday, November 21, 2003 for this No. one point. Click here for more coverage of Supreme Court Visiting at ERISAClaim.com.   This new Rand/Harvard study warns that "Although the end result for consumers is the same in each of these cases, the messages sent by plans to consumers and medical groups are not. Goodwill payments imply inappropriate use of the ED (notwithstanding the fact that actual merit might not have been assessed). Merit-based overturns, on the other hand, signal an error in utilization review and instruct medical groups about the proper limits of coverage, instructions that medical groups cannot ignore because they must meet the cost of these claims. Hence, merit-based overturns perform a valuable signaling function, akin to the role of judicial precedent in the law. Unless plans invest additional effort in educating utilization reviewers about erroneous decisions for which they are not held financially accountable, goodwill payments of potentially meritorious cases limit opportunities to forge consensus about the limits of the prudent layperson standard and to disseminate accumulated knowledge about its meaning."   "Prudent Layperson" Laws Do Not Increase Inappropriate ED Visits (Reuters via Medscape; one-time registration required)   "However, some compliance problems did emerge. Some insurers, Hall told Reuters Health, initially deny ED claims and then "quickly reverse" their decision if challenged.   "There are two take-home messages for health professionals," Hall said. "One, insurers much less often question the appropriateness of emergency services and two, if insurers initially deny coverage for emergency care, providers or patients should appeal."   The impact and enforcement of prudent layperson laws (Mark A. Hall, JD, Annals of Emergency Medicine Online, May 2004 • Volume 43 • Number 5) [ABSTRACT]  [FULL TEXT] [ PDF] Importantly, ERISA claim regulation and definition of "claim involving urgent care", 29CFR2560.503-1 (m)(1) - Claims Procedure, has provided governing solutions to "disagreement between lay and expert judgments about what constitutes emergency care under the prudent layperson standard." for these privately insured enrollees. And "Unless plans invest additional effort in educating utilization reviewers about erroneous decisions for which they are not held financially accountable," and ERISA claim regulation and  definition of "claim involving urgent care'', goodwill solution will result in backslash for more disasters in Emergency Department across the country.   If 80% of the health-care claim and 60% of health expenditures are governed and regulated by ERISA, ERISA plan's "insurance policy" is controlled by each plan's Summary Plan Description (SPD), and each claim dispute is resolved under ERISA claims procedure regulations, such "contractual expertise", called for by our Rand/Harvard experts, must be from ERISA claim procedure specialists. Therefore, it is absolutely clear that our nation must provide a solution to health-care crisis by urgently establishing an industry or profession that will possess not only clinical expertise but also, and more importantly, ERISA contractual expertise, ERISA claim procedure expertise. These three valuable Harvard/Rand studies have pointed out the direction but failed to provide a turnkey practical solution.   Now that both Aetna and CIGNA have settled the class-action lawsuits by 950,000 physicians and agreed to process appeals in accordance with ERISA claim regulations for both ERISA claims and non-ERISA claims, and to establish external review boards for Billing and Coding Disputes, Medical Necessity Disputes and Policy Coverage Disputes, in compliance with state external review laws, however external reviews will not be available until internal appeals/ERISA appeals are completely exhausted.     Aetna Reports First Quarter Results HARTFORD, Conn.--(BUSINESS WIRE)--April 29, 2004--   "-- First-quarter operating earnings, excluding favorable reserve development, of $1.75 per share, compared with Thompson/First Call mean of $1.72, a 31 percent increase over prior-year quarter -- First quarter net income of $2.28 per share -- Medical membership increase of 342,000 from year-end 2003"   "We also announced several new initiatives to reduce complexity for and improve communications with physicians, including a new information resource, a billing dispute mechanism, and dedicated service centers. And the National Advisory Committee of Practicing Physicians, recently formed as a direct result of our 'new era of cooperation' agreement with physicians, held its first meeting."   All other 8 major insurance companies named in class-action lawsuits have refused to settle, even if federal court would rule for physicians, the Aetna and CIGNA settlements will be "as good as it could get" from the rest of insurers and MCO's as evidenced in Aetna and CIGNA settlements with physicians.   "Forty states required individuals to first exhaust their health policy’s internal appeals and grievance process before seeking external review." (GAO, September 2003, Page 46)  The health policy’s internal appeals and grievance process = ERISA appeals 80% of the time. Unless physicians understand and complete ERISA internal appeals, all of those "a love fest" and "victories" from class-action settlements would mean a fantasy of "a love fest"  to any physicians.   From medical coders and billers & insurance claim processors to lawyers for physicians and insurance companies, the occupational and professional gap is a vacuum and too huge to be ignored by both insurance industry and health-care provider industry. A new occupation or profession has to be developed to handle such huge crisis: ERISA health-care Claim Specialists and Department, to bridge the gap FROM medical coders and billers & insurance claim processors TO lawyers.   Nixon Peabody's August 2004 Benefits Briefs: Legal Developments for Employee Benefits (PDF) (Nixon Peabody LLP) 6 Pages, Excerpt: "Getting Burned by Ignoring People with “Colorable” Claims to Plan Participation You surely know that plan participants and beneficiaries are entitled to receive copies of relevant plan documents, if they request them. You also should know that if you fail to provide requested documents within thirty days a court can impose a penalty of up to $110 per day for each day you are late. What if you turn down a request from someone who is not a participant or beneficiary but thinks he is? You could be in for a penalty if he has a “colorable” claim. Lowe v. McGraw-Hill, 361 F.3d 335 (7th Cir. Mar. 15, 2004)."    Aetna (DOL/ERISA), First Health, Blue Cross Blue Shield are ready to comply with new federal regulation (BCBSIL) (BCBSMI) (BCBSCNY) (BCBSNE) (CareFirstBCBS) & (BCBSAL),  are you ready to get paid faster and fairer?   From Aetna's ERISA yesterday (Aetna Video Shows ERISA Patients Mistreated) to Aetna's ERISA today (DOL/ERISA) = Aetna ERISA Actions or intention in compliance and in control.   From AMA's ERISA yesterday (The latest Harvard & RAND study) to AMA's ERISA today (JAMA Editorial) =ERISA Actions or Not?   That's why physicians, healthcare providers and hospitals must wake up on ERISA now!   "Congress library report", "Minneapolis memorandum" and "Phoenix memorandum" should have been sufficient intelligence for executive decision-making on health-care Oct. 11 fact card.   In today's progressively worsening health-care and budget crisis since World War II, any health-care executive strategy, without mastering or complying with ERISA, has been proven failing since inception of managed care practice, unless a new health-care reimbursement and compliance model is established and implemented to immediately create a new line of ERISA reimbursement personnels and occupation, "ERISA Healthcare Claim Appeals and Reimbursement Specialists and Departments", no one in this country can stop and survive our failing health care system crisis. In 2002, our national health-care expenditure has reached $1.55 trillion, 14.9% of GDP, with a predicted 10% increase each year According to latest hospital CEOs survey conducted by American College of Health-care Executives in November 2002, of the 984 hospital CEOs respondents, 65% named reimbursement issues in top three concerns. After the failure of every managed care industry model and legislative campaign for Patients' Bill Of Rights, as well as physicians and patients nationwide class actions in managed care reimbursement disputes, a new ERISA regulation, went into effect Jan. 01, 2003, solely designed for regulatory protections and resolutions in most healthcare claim disputes, has been completely ignored by nation's health-care executives as ERISA was in past two decades. The prevalent industry practice has proven to be risky by increasing service charges, maximum reimbursement can only be achieved through compliance with ERISA, among many other applicable federal and state laws and regulations.   AMA has finally noticed the existence and effective date of this new federal claim regulation, as described in its January 20, 2003 online edition of American Medical News: "Federal regulations that dictate rapid turnaround times for health plan claims and appeals quietly went into effect this month, with little noise from the managed care industry." However AMA has failed, as it did in past 28 years, to practically and meaningfully understand the ERISA and its significance as protections for health-care providers, entire industry has failed to offer any educational programs and occupational trainings to health-care providers in this most important federal law and regulation that governs and regulates up to 80% of health-care claims and 60% of U.S. healthcare expenditures.   As reported by AMA as to the time it may take for this new federal claim regulation to take effect in marketplace, Jeffery Mandell, president of the ERISA Law Group in Boise, Idaho, states "it often takes years, even decades, for the marketplace to fully adopt new regulations". Life is too short, our nation's health-care system is going through the worst crisis since World War II and can't afford another 28 years to realize and implement the ERISA regulations. We, everyone including health-care providers, legislators, regulators and insurance companies, should take immediate actions to educate everyone in the system and to implement this new federal claim regulation as we are fighting against terrorists to save our nation's health-care system from worse-than-terror-war crisis.   Health-care executives have obligations to save not only their hospitals but also national health-care system from the worst healthcare crisis since WW II, through understanding, complying through implementation of ERISA claim procedure in claim appeals and reimbursement practice.   The prevalent industry practice has proven to be risky by increasing service charges, maximum reimbursement can only be achieved through compliance with ERISA, among many other applicable federal and state laws and regulations.   Traditionally health-care providers and facilities have little or no knowledge of ERISA claim procedures when dealing with health-care claim disputes and denials.  They will outsource billing and coding to independent services in hope to recover these claims to reduce denial rates, while most of these claim denials are not in dispute of coding and billing, and independent coding and billing services offer only billing and coding services.  Or they will demand physicians for better clinical documentations in hope to reverse denial decisions while documentations are not in dispute for the denied claims.  Without any luck and success and having tried every efforts through state and national medical associations for organized fighting back campaign with little or no success, most of them automatically turn these denied claims to outside consumer collection agencies to collect from patients, while collection agency generally only collects undisputed debts instead of disputed or denied claims for reimbursement.  Under current recession economy and escalating health cost environment, most of these consumer collection practice resulted little success in collecting money from patients, but more frustrations, and loss of marketing share with negative public relations or possible backfiring from patients with lawsuits for medical malpractice or consumer fraud complaints, which in turn significantly contributed to "medical malpractice crisis", as often regarded by "tort reformers" as frivolous malpractice lawsuits or triggering fraud investigations against hospitals and providers.   Uninsured patients sue Advocate Crain's Chicago Business, IL - Nov 19, 2003 A group of former patients on Wednesday sued Oak Brook-based Advocate Health Care System, alleging the hospital chain inflates prices for uninsured patients ...   Uninsured patients pay more for medical care The News-Press, FL - Oct 28, 2003 "... Florida attorney general to take up its cause, accusing hospitals of unfair and deceptive billing practices. The organization found similar hospital billing ..."   Critical condition Sacramento Bee, CA - Oct 26, 2003 "... the US Office of Inspector General ... who replaced Hal Chilton as the hospital's ... in August with the US attorney's ... unnecessary procedures, then fraudulently billing ..."   Any traditional and conventional appeals without ERISA COMPLIANCE are "squeaky wheel appeals" for any ERISA claim denials and delays, 80 percent of U.S. Healthcare claims and 60% of U.S. Healthcare expenditure. Only appeals with full ERISA compliance will ensure maximum reimbursement or crisis turnaround at minimum cost and frustrations. 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. We are the only company in today's market providing ERISA healthcare claim compliance practice FOR health-care provider prospects, focusing on one-stop shop services from educating, consulting, publishing and ERISA claims recovery.   CALL:  1-630-736-2974 Please e-mail for more details

February 5, 2003, H. R. 957 (pdf) February 5, 2003, H. R. 956 (pdf)   Norwood Introduces The Patient Protection & ERISA Clarification Acts

Please e-mail for details     Why ERISA Brainstorming for Healthcare Executives?

1.     ERISA regulates up to 80% of health-care claims or 60% of health expenditures in the U. S. ($1.55 trillion in 2002), and has never been understood by health-care executives; 2.     Health-care executives have never been practically and meaningfully advised on ERISA education and strategy that covers ERISA statutes, regulations, case laws, claim procedure and dispute as well as health-care bottom-line: reimbursement under current managed care/ERISA environment; 3.     Health-care claim denial problems have fundamentally threatened health-care providers business survival; 4.     Up to 1/3 health-care claims was completely denied, rest of them partially and significantly denied.  Up to $600 billion claims were denied health-care claims in 2000.  Physicians Are at Breaking Point in heir Business Survival As a Result of the Managed Care Nightmare and Claims Denials under ERISA Shield 5.     $1.55 trillion were spent in national health-care in 2002, 14.9% of GDP, out of which $207.2 billion were out-of-pocket payments, rest of them are health-care claims through third party reimbursement claims 6.     Health insurance premium increased 14%-20% this year and almost every major health insurers are cutting jobs to cope with crisis; 7.     New trend in health-care funding and insurance from MSA, FSA, DCP as tax incentives to employee high premium and high deductible might fundamentally change U.S. health-care platforms; 8.     State law legislations (Prompt Pay and Patient Rights) have proven to be little or no protection (80% of ERISA claims); Patient Bill Of Rights, a revision of ERISA, will not provide any meaningful protection to health-care providers unless health-care executives really understand ERISA and its practical implementation in managed care environment, something remains to be mystery in reality and miracle in legislation; 9.     ERISA has been around for 28 years without any Executive 101 Briefing while ERISA relentlessly regulates 80 percent of U.S. health-care costs; 10.  New Federal Claim Procedure, to be effective January 2002, has been a monopoly for insurance/benefits executives but practically immune or allergic to health-care executives while it has provided health-care providers with best and maximal protections against improper denials of medical necessity, usual customary and reasonable, policy exclusion, PPO discount and pre-existing conditions, Q-C16, Q-C17, Q-D9 & Q-D10; 11.  Traditional Assignment of Benefits Form used in hospitals and physician's offices does not provide any rights for physicians to dispute with insurance companies over claim denials except for only receiving undisputed and paid claims, according to new government guidance for new claims procedure, Q-B2; 12.  Only with proper understanding of what constitutes a sufficient designation of authorized representative, as required by new regulation, to ensure you to obtain ERISA rights guaranteed by federal law and to enjoy maximal protection to protect your business survival and prosperity. 13.  Traditional Coding and Billing, documentation and electronic claim submission implementations have been proven marginal successful while many hospital’s reimbursement rate are well below 50%-25% across the country.

Please e-mail for details

 

Fighting ERISA Plan Payment Denials by Savvy Use of Administrative Appeals March 2002, Reprinted with Permission from Managed Care Contracting & Reimbursement Advisor by Brownstone Publishers, Inc.

Challenge UR Company's Qualifications to Fight Claim Denial  May 2002, Reprinted with Permission from Managed Care Contracting & Reimbursement Advisor by Brownstone Publishers, Inc.

Fighting ERISA Plan Payment Denials by Savvy Use of Administrative Appeals July 2002, Reprinted with Permission from Radiology Administrator's Compliance & Reimbursement Insider by Brownstone Publishers, Inc.

 

How Private Health Insurance Works: a Primer  (Henry J. Kaiser Family Foundation) Report    Excerpt: "This primer ... examines the structure and operation of private health insurance-- including the types of organizations that provide it, how managed care is delivered, and how risk pools work-- and describes how private health insurance coverage is regulated under state and federal laws. The primer explains how the current nature of private insurance relates to key issues facing federal and state policymakers."   EBRI Frequently Asked Questions About Benefits

NAIC Members Adopt Discretionary Clause Model Act Excerpt: "Model Helps Ensure Consumer Health Insurance Claims are Subject to a Fair Review   PHILADELPHIA (June 9, 2002) — Members of the National Association of Insurance Commissioners (NAIC) today adopted the Discretionary Clause Model Act at the association’s Summer National Meeting here.   The act, which was developed by the NAIC’s ERISA Working Group, prohibits the use of discretionary clauses in health insurance contracts.   “Discretionary clauses are an effort to give an insurance company full and final discretion in interpreting benefits and administering an insurance contract,” said Maryland Insurance Commissioner Steve Larsen, who chairs the Health Insurance and Managed Care Committee. “This places consumers at a significant disadvantage when they are seeking to overturn the denial of benefits under an insurance policy.”...."       UT Admin Code R590-218. Permitted Language for Reservation of Discretion Clauses.     Licensing of ERISA-Covered Benefit Plan Administrator, New York State Insurance Department, January 26, 2000   Letter opinion per CIC §12921.9 : Discretionary Clauses, (PDF) John Garamendi, Insurance Commissioner, DEPARTMENT OF INSURANCE, STATE OF CALIFORNIA, February 26, 2004         NAIC: UTILIZATION REVIEW AND BENEFIT DETERMINATION MODEL ACT      NEW Utah State law Mandates ERISA Claim Regulation (Copyright © 2004 by Jin Zhou,  ERISAclaim.com) Did you know that,  effect on March 1, 2004, a NEW Utah State law, UT Admin Code R590-203. Health Grievance Review Process and Disability Claims., has mandated every health insurer and HMO conducting business in the State of Utah to comply with ERISA claim regulation, regardless if the plan is actually an ERISA plan?   This is the first state law for health insurance and manage care that mandates and clones ERISA claim regulation at state-level. More and more states are expected to follow.   UT Admin Code R590-203. Health Grievance Review Process and Disability Claims. "R590-203-2. Purpose. The purpose of this rule is to ensure that health insurer's grievance review procedures for individual and employer health benefit plans comply with the Department of Labor, Pension and Welfare Benefits Administration Rules and Regulations for Administration and Enforcement: Claims Procedure, 29 CFR 2560.503-1, Utah Code Sections 31A-4-116 and 31A-22-629."     (Bulletin) (Utah Code Section 31A-22-629)

Consumer Protections under ERISA and California Law Compared  (California HealthCare Foundation)   Excerpt: "ERISA prevents states from directly regulating health insurance arrangements established by employers, but allows states to regulate the indemnity insurers and health plans with which employers contract.... [C]onsumer protections vary depending upon whether an employer decides to retain the risk of paying medical claims (that is, to 'self-insure' the employee plan) or to purchase group insurance from a state-licensed insurer or managed care organization."   Document Downloads from CHCF.ORG ERISA and Variation in California Health Plan Consumer Protections (234K) Regulation of ERISA Plans: The Interplay of ERISA and California Law (534K)

Department Of Insurance Web Sites for All 50 States

(Peer Review) ORDER Final Order S T A T E  O F  N O R T H  D A K O T A MARKET CONDUCT EXAMINATION REPORT - CHIROPRACTIC BENEFITS NORIDIAN MUTUAL INSURANCE COMPANY DBA BLUE CROSS BLUE SHIELD OF NORTH DAKOTA

February 5, 2003, H. R. 957 (pdf) February 5, 2003, H. R. 956 (pdf)   Norwood Introduces The Patient Protection & ERISA Clarification Acts     Few California Residents, Providers Aware of Law on Independent Review of Health Plan Decisions (KaiserNetwork.org)   Excerpt: "Many managed care patients and physicians in California are unaware of a state program that allows patients to appeal the decisions of their health plans, according to a report issued last week by the California HealthCare Foundation, the Los Angeles Times reports."   "The report recommended that the state DMHC develop a "how to" guide about the independent review program and distribute the guide in physician offices and employer human resource departments to increase participation. The report also recommended a campaign to explain the program to physicians and establish a system to ensure that health plans implement the decisions of the independent review board "in a timely manner," the Times reports."   American Medical Association: Here's Five Ethical Rules for Managed Care Plans (American Medical Association)     Medicare Modernization Update-Released and Pending Manual Instructions (RELATING TO APPEALS) 921 Provider Education and Technical Assistance 931 Transfer of Responsibility for Medicare Appeals 932 Process for Expedited Access to Review 933 Revisions to Medicare Appeals Process 934 Prepayment Review 935 Recovery of Overpayments 937 Process for Correction of Minor Errors and Omissions without Pursuing     Appeals Process 939 Appeals by Providers when there is no Other Party Available 940     Revision to Appeals Timeframes and Amounts 940A Mediation Process for Local Coverage Determinations 952 Revisions to Reassignment Provisions   TITLE III—COMBATTING WASTE, FRAUD, AND ABUSE 301  Medicare Secondary Payor (MSP) Provisions   CMS: Contact Your Carrier/Fiscal Intermediary   via Toll-Free Numbers and Websites -- A listing of the new toll free numbers that CMS has installed at Medicare contractor sites         National Correct Coding Initiative Edits - Version 11 (Effective April 1, 2004 - June 30, 2004) Column 1/Column 2 Correct Coding Edits (formerly Comprehensive/Component Edits)   Mutually Exclusive Edits NCCI Policy Manual for Part B Medicare Carriers Medicare Claims Processing Manual (Sec. 20.9) NCCI Questions and Answers NCCI Edits Program Transmittals National Correct Coding Edits for the Hospital Outpatient PPS - Version 10.0  (Effective April 1, 2004 - June 30, 2004) Column 1/Column 2 Correct Coding Edits (formerly Comprehensive/Component Edits) Mutually Exclusive Edits NCCI Questions and Answers NCCI Policy Manual for Part B Medicare Carriers Comprehensive Error Rate Testing (CERT) Program FY 2003 IMPROPER MEDICARE FEE-FOR-SERVICE PAYMENTS REPORT (Short Version) (PDF 671 KB) AMNews: Oct. 20, 2003. HHS inspectors' action plan reveals hot buttons for fraud ... American Medical News AMNews: Dec. 8, 2003. Primary care troubled by coding errors ... American Medical News White Paper: Health Care Fraud-- a Serious and Costly Reality for All Americans (PDF) (National Health Care Anti-Fraud Association - www.nhcaa.org) "Aetna and CIGNA Settlement Secrets" "Talking Points"   FALLICK v NATIONWIDE MUTL INS Usual, Customary and Reasonable Charges (UCR) Payments Go Under a Microscope (washingtonpost.com) January 12, 2004 "CareFirst officials said the audit of 2,800 doctors was triggered by an earlier examination of several thousand claims that found 9 of every 10 were inaccurate. "The doctors, we're not saying we don't trust them," said Jeff Valentine, a CareFirst spokesman. "But as President Reagan said a number of years ago: 'Trust, but verify.' "   "The largest insurer of all, the federal government, recently estimated that the Medicare program overpaid doctors, hospitals and other health-care providers by $11.6 billion in 2002, according to an audit of 128,000 claims. The audit found many providers submitted insufficient documentation (45 percent), billed for medically unnecessary services (22 percent) and used incorrect codes to describe patient visits (12 percent)."   "A larger audit is planned this year. "The digging now is much deeper," said Leslie V. Norwalk, chief operating officer of the Centers for Medicare & Medicaid Services, the government agency known as CMS. "Any dollar overpaid is a dollar too much."   "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."       Press Release      Complaint (pdf)   U.S. FILES COMPLAINT AGAINST NATIONAL ACCOUNTING FIRM UNDER FALSE CLAIMS ACT "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." ..... "It is the responsibility of an independent reviewer to be alert to fraud and abuse and certainly not to ignore it," said Meehan. "In this case, as the complaint alleges, Ernst & Young kept itself deliberately ignorant of the facts."   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"   Employers Audit Workers' Health Claims (Wall Street Journal via SFGate.com) & baltimoresun.com - Health plan 'stings' on rise 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."   More Employers Checking Eligibility of Dependents Receiving Health Coverage (KaiserNetwork.org) Employers Check Family Ties to Cut Health Care Rolls (USA TODAY) "* Ford Motor, which spent $3.2 billion on health care last year, is also looking to recoup some costs from workers. It says intensive audits found 50,000 ineligible dependents since 2000, reducing its health care rolls by about 10%. Some employees have to pay up. The audits will continue. ''We've saved millions of dollars,'' spokeswoman Becky Bach says." 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 Unusual provider billing practices. Discrepancy between the submitted diagnosis and the treatment. Diagnoses or treatments that are outside the practitioner’s scope of practice. Claims that are resubmitted with coding changes to gain benefits. Alterations on claim submissions. Pressure for quick claim payment." Excellus BlueCross BlueShield Fraud Recovery and Prevention Efforts Net Over $7.5 Million   "The SIU received approximately 1,000 calls to its Fraud Hotline this past year. Tips are also received via e-mails and letters to the company." "The most common types of insurance fraud include: Billing for services not provided. Billing for higher-level services than those actually performed (known as "upcoding.") Submitting a claim for a fictitious physician or ineligible dependent. Falsifying the identity of a service provider to receive payment for services rendered by a non-covered and/or non-licensed provider. An example of this is billing for a massage at a fitness center as licensed physical therapy. Securing prescriptions for controlled substances that are then re-sold."   BlueCross Seeks Consumer Help in Fighting Insurance Fraud   Help Fight Fraud - What is Health Care Fraud? (bcbst.com)   Labor Department Sues Corporation For Violating Federal Employee Benefit Law (Release Date: 02/02/2004)   Effective Corporate Compliance Programs for Health Care Organizations (pdf) (Ernst & Young) "An executive summary to our 52-page overview of the government's efforts to detect and punish health care fraud and abuse, with guidelines on how organizations can develop an effective corporate compliance program. Strengthening Ethical Cultures: The Emerging Role of Compliance Programs and Officers in Managed Care Organizations (Ernst & Young)     United States of America v. Thomas Bruce Vest, also known as T. Bruce Vest, doing business as Doctors Clinic   Appeal from the United States District Court for the Southern District of Illinois, Benton Division. No. 93 CR 30053--J. Phil Gilbert, Chief Judge. Argued December 13, 1996--Decided June 25, 1997   Before Cudahy, Ripple, and Kanne, Circuit Judges "Second, the Government presented 36 patients who testified that during their visits to the Doctors Clinic, they did not report many of the symptoms and past conditions that Vest recorded on their medical records. On cross-examination, defense counsel used the patients' pre-visit and post-visit medical records to impeach the patients' recollections. If, for example, a patient denied that she reported dizziness to Vest, defense counsel was allowed to cross-examine the witness with medical records showing that the patient reported dizziness either before or after visiting the Doctors Clinic. Third, the Government presented four medical doctors who testified that many of the tests Vest ordered were medically unnecessary." UW failed to address overbilling, agreed to pay a historic $35 million settlement yesterday (The Seattle Times)   "As the University of Washington agreed to pay a historic $35 million settlement yesterday, U.S. Attorney John McKay said his investigation found that Medicare and Medicaid overbilling was common knowledge at the school's medical centers, but the UW did not address the problems." Table of Contents - Health Care Fraud: Enforcement and Compliance - LawCatalog.com   PROSECUTING AND DEFENDING HEALTH CARE FRAUD CASES, WITH 2003 CUMULATIVE SUPPLEMENT (Author(s):  Michael K. Loucks and Carol C. Lam)   Text of HHS Semiannual Regulatory Agenda (PDF) (Department of Health & Human Services) 12/13/2004   MEDICARE OVERPAYMENTS REACHED NEARLY $20 BILLION IN 2003, NEW SURVEY FINDS (PharmExec)   CMS ANNOUNCES IMPROVED EFFORTS TO REDUCE MEDICARE PAYMENT ERROR RATES (12/13/2004, CMS Press Release)   Community Benefit Reporting – Guidelines and Standard Definitions for the Community Benefit Inventory for Social Accountability CHA and VHA Revise Accounting Guidelines for Charity Care.   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 HEALTH PLANS FAIL TO DISCLOSE REQUIRED COVERAGE INFORMATION 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.     State of New York Office of the Attorney General Health Care Bureau   New York Managed Care Consumer Bill of Rights Compliance Survey: The Failure of New York HMOs To Provide Important Coverage Information To Consumers   Eliot Spitzer Attorney General | Printable PDF Version | Press Release Survey Report - (HTML Version | PDF Version)     Text of IRS Notice 2004-2: Guidance on Health Savings Accounts (PDF) (Internal Revenue Service) 13 pages. Excerpt: "This notice provides certain basic information about HSAs in question and answer format, without attempting to enumerate all of the specific rules that apply under section 223. The notice is divided into five parts. Part I of the notice explains what HSAs are and who can have them. Part II describes how HSAs can be established. Parts III and IV cover contributions to HSAs and distributions from HSAs. Part V discusses other matters relating to HSAs." Overview of Health Savings Accounts With Chart Comparison to Archer MSAs, HRAs and FSAs (PDF) (Miller & Chevalier Chartered)   How Health Savings Accounts Compare To FSAs and HRAs (Groom Law Group)   Zhou's Medical Inflation Projection Through 2008: $1,000 Deductible (HDHP / HSA) + $1,500 Discount (HHS / Indigence) [Deductible + UCR + PPO Disc.]  =  "Discretionary Spending" + "Price Gouging" =   500% Medical Inflation in 5 years      ERISA Power Guides (Copyright © 2004 by Jin Zhou,  ERISAclaim.com) What You Should Know about Filing Your Health Benefits Claim (Claims Card) Filing A Claim For Your Health Or Disability Benefits (PDF) 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 DOL/EBSA Organization Chart/Regional and District EBSA Offices | By Topic | By Audience | By Organization | By Location   New Federal Reports Highlight Issues in Health Care Quality (The Commonwealth Fund) Excerpt: "The Department of Health and Human Services has released two reports that represent the first comprehensive national effort to measure the quality of health care in the U.S. and assess disparities in access to and utilization of care." The National Healthcare Quality Report (http://www.qualitytools.ahrq.gov/)   The National Healthcare Disparities Report (http://www.qualitytools.ahrq.gov/)   December 03, 2004: NEW CMS STUDY SHOWS MEDICARE, MEDICAID PAID FOR MORE THAN HALF OF ALL SENIOR HEALTH CARE   ERISA OVERHAUL OF U.S. HEALTHCARE FOR SURVIVAL   "Zhou's Model of Prudent Health Care" Are All Consultants Corrupt? (Fast Company)     The First Overhaul for U.S. Health care and GM Is to ERISA-Overhaul GM Health Care Model with Followings: ERISA Compliant SPD with Complete Benefits Coverage, Limits & Exclusions; ERISA Compliant Claims Procedure as the Only Rule for Every One; Elimination of Any Third-Party Managed Care Contracts, UCR & "Medical Necessity" (GM Current Model: $5.1 billion/yr, $1,400/vehicle) (GM says health care obligation hit $67.5 billion in 2003) Rx-1  $$$$$$$$$ERISA$$$$$$$$$$  Rx-2 Health Spending Projections Through 2013 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) U.S. Health-care Crisis & ERISA Criminal Enforcement CBO's analysis of the President's budgetary proposals for fiscal year 2005 Fact Sheet: Affordable Health Care for America's Families (White House)   Zhou's Medical Inflation Projection Through 2008: $1,000 Deductible (HDHP / HSA) + $1,500 Discount (HHS / Indigence) [Deductible + UCR + PPO Disc.]  =  "Discretionary Spending" + "Price Gouging" =   500% Medical Inflation in 5 years      DOL-Reporting and Disclosure Guide for Employee Benefit Plans (pdf) Compliance Assistance for Group Health Plans (Top 15 Tips) 950,000 MD's Settled With Aetna & Cigna on ERISA "Aetna and CIGNA Settlement Secrets" ERISA Certification Programs for Maximal Reimbursement What You Should Know about Filing Your Health Benefits Claim HIPAA Nondiscrimination Requirements Frequently Asked Questions   A New Diagnosis & Solution: EFS-- ERISA FAILURE SYNDROME--Fatality: 31 YOA   ERISA Failure, Noncompliance and Nonenforcement of ERISA SPD and Claims Procedure Rules, Is the Damaged or Missing Foam on U.S. Healthcare Wings! HMO Crisis Is Really An ERISA Crisis! HMO & PPO Managed Care Contracting to  Disregard & Substitute ERISA SPD & Claims Procedure Is The Primary & Inevitable Cause of Medical Inflation Costly Managed Care & Medical Malpractice Lawsuits American Job Export!   ERISA Failure Damages Are Greater Than 9/11 and Pearl Harbor Tragedies Combined U.S. Health-care Crisis & ERISA Criminal Enforcement   Only practical solution is to cut the skyrocketing healthcare care costs and increase the healthcare coverage and benefits at the same time without having to go to Congress to reinvent another new "Mars Project" or "Universal Uninsured Bill of Right" - "John Q. ERISA Enforcement".   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. 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." Licensing of ERISA-Covered Benefit Plan Administrator, New York State Insurance Department, January 26, 2000   Letter opinion per CIC §12921.9 : Discretionary Clauses, (PDF) John Garamendi, Insurance Commissioner, DEPARTMENT OF INSURANCE, STATE OF CALIFORNIA, February 26, 2004   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."   Law Professor Looks at Criminal Prosecution for HMO Treatment Denial (Prof. John A. Humbach published by the Health Administration Responsibility Project (harp.org))   Trends and Indicators in the Changing Health Care Marketplace, 2004 Update (The Henry J. Kaiser Family Foundation) Excerpt: "Trends and Indicators in the Changing Health Care Marketplace, 2004 Update (April 2004) presents information on key trends in the health care marketplace of interest to policymakers, public interest groups, the media, and industry analysts and leaders.' Click on any of the 'sections' listed in the right-hand menu bar on the target page. 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." 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     DOL + DOJ Enforcement of ERISA   &        HHS Works with ERISA (+77 Millions/4 Yrs)   State Insurance Department in All 50 States Promote & Coordinate with ERISA  NAIC ERISA Working Group   Health Benefits Laws By State (Interactive Tools From Insure.com) Health Insurance Mandates in the States, 2004: a State-by-State Breakdown ... (PDF) (Council for Affordable Health Insurance) Kaiser statehealthfacts.org Consumer Guides for Health Insurance in Every State and the District of Columbia (Georgetown University) View a 5-minute clip Paper Chase ERISAclaim.com - U.S. Health-care Crisis & ERISA Criminal Enforcement To Avoid "John Q. ERISA Enforcement"