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Moukawsher & Walsh, LLC
Pension and Employee Benefit Law


SPD's for FEHB

FEHB Open Season and FSA Open Season


Federal Employees Health Benefit Plan


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FEHB Plan Brochures


Links to Plan Brochures for 2003


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TRICARE Handbook



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for employees and retirees

January 2003 (pdf)



[PDF] Medicare Secondary Payer (MSP) Manual


[PDF] Program Memorandum


[PDF] Medicare Secondary Payer Statute: Medicare Set-Aside Arrangements


[PDF] GAO-04-783 Highlights, MEDICARE SECONDARY PAYER: Improvements


[PPT] Medicare Secondary Payer Registration Questionnaire



Physicians CCI EDITS



U.S. Healthcare Crisis Turnaround?

U.S. A.

Drs. & Hospitals Employers

$1.0 Trillion / Year

$$$ ERISA $$$

50% Savings

The Only Company with Compliant Solutions for All of You

New Federal Health Claims & Appeals Laws & Regulations

for 193 Million Americans

Effective 09-23-2010

©2010, Jin Zhou,

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

President Obama Signing Health Bill on 03/23/2010

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

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

DOL Seal - Link to DOL Home Page



(Links to DOL) ©2010, Jin Zhou,

Patient Protection and Affordable Care Act

Statutory Laws [PDF] [PDF]



Affordable Care Act Regulations and Guidance
bullet 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
bullet Interim Final Rules on Internal Claims and Appeals and External Review Processes: News Release • Regulation • Fact Sheet • NAIC Uniform External Review Model Act
bullet 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
bullet Grandfathered Health Plans: Fact Sheet • Regulation • FAQs • Table • Model Notice
bullet Extension of Coverage For Adult Children: Fact Sheet • Regulation • FAQs • IRS Guidance
bullet FAQs on Health Care Reform and COBRA


bullet House Committees Health Insurance Reform at a Glance: Summary • Implementation Timeline • Consumer Protections • For Employers
bullet White House Web Page on Health Reform
bullet HHS Health Reform Web Site

Employee Retirement Income Security Act — ERISA

bullet ERISA Claims Procedure, 29 CFR 2560.503-1: Regulation FAQ Fact Sheet Claims Guide Claims Card
bullet Amendments to Summary Plan Description Regulations, 29 CFR 2520.102-3: Regulation Fact Sheet News Release SPD Rights Fact Sheet SPD from DOL
bullet Health Claims Related Information
bullet Consumer Information on Health Plans
bullet Compliance Assistance for Health Plans  Fiduciary Guide
bullet Health Benefits Education Campaign

Webinars, Seminars & Certification Classes for New Federal Health Claim Appeals Regulations - Free Webinars - New Federal Claims & Appeals Regulations, Effective Sept. 23, 2010, for 193 Million Americans Seminars - 2010 Two-day Basic ERISA Appeal Seminars - Denials and Overpayment Appeals - 2010 PPACA & ERISA Claim Specialist Certification Programs in Chicago, Illinois  Create An Appeal Department for Your Hospital or Practice (In-house, onsite ERISA Claim Specialist Certification Programs)
 - 2010 Claim Denial & Overpayment Dispute Two-day ERISA Appeal Seminars, - 2010 ERISA Claim Specialist Certification Programs in Chicago, Illinois


New ERISA Appeal Book with 2010 Major Updates  $450  & $150 (Updates only with previous purchase) - ERISA Litigation Support, Facts + Laws + Strategies = Winning Lawsuit When Inevitable - Free ERISA Webinar, The Beginning for $6 Trillion Healthcare Denial Management Market


Medicare & ERISA


Medicare Over-payment, Medicare Secondary Payer & ERISA



Return to Home DOL Seal - Link to DOL Home Page

Medicare Secondary Payer and You, You
AND you, For

Health Plans, TPA's, Physicians, and You

Medicare Coordination of Benefits




Retiree Health Benefits Fact Sheet (DOL)

If You Retire Early...

You Should Know-Coverage Can Change

Review Your Plan Documents

Medicare Secondary Payer (CMS)

"Medicare Secondary Payer (MSP) is the term used by Medicare when Medicare is not responsible for paying first. (The private insurance industry generally talks about "Coordination of Benefits" when assigning responsibility for first and second payment.)


The term "Medicare Secondary Payer" is sometimes confused with Medicare supplement. A Medicare supplement (Medigap) policy is a private health insurance policy designed specifically to fill in some of the "gaps" in Medicare’s coverage when Medicare is the primary payer. Medicare supplement policies typically pay for expenses that Medicare does not pay because of deductible or coinsurance amounts or other limits under the Medicare program."


Breaking News:  Employer Must Reimburse Medicare Over Payments under MSP


Telecare Corp. v. Leavitt

(Fed. Cir. 2005)


CMS/MM: What Physicians and Other Suppliers Should Know About Medicare Overpayments - A two sided tri-fold brochure (August 2004) (PDF format 19Mb)


CMS: Notice of New Interest Rate for Medicare Overpayments and Underpayments (R63FM) IMPL DATE: 2/8/2005


CMS: Revision to the Beneficiary Notification Process when Recovery is Sought from the Provider (R70FM) IMPL Date: 6/27/2005 - CMS New Appeal Rules: "Overhaul of the Medicare Claims Appeals System"


CMS 2005 Transmittals
234 kb R42MSP 10/28/2005 PUB 100-04 Updates to MSP Accounts Receivable (AR) Write Off Procedures 11/28/2005 4027
175 kb R40MSP 10/21/2005 PUB 100-05 Updates to the Group Health Plan (GHP) Demand Letters 4/3/2006 4012
123 kb R41MSP 10/21/2005 PUB 100-05 Full Replacement of and Rescinding Change Request (CR) 3504--Modification to Online Medicare Secondary Payer Questionnaire 1/21/2006 4098
939 kb R35MSP 9/27/2005 PUB 100-05 Updates to the Group Health Plan Identification and Recovery Processes 10/26/2005 4015
94 kb R33MSP 8/12/2005 PUB 100-05 Working Aged Exception for Small Employers in Multi-Employer Group Health Plans (GHPs) 5/20/2005 3768
155 kb R75FM 8/12/2005 PUB 100-06 New Thresholds for 2nd Demand Letter for Physicians/Suppliers 9/6/2005 3932


Medlearn Matters Articles Table

Table is pre-sorted by Article Release Date. Click on any column heading to sort the table to individual needs.   Ascending: Information for Providers  Descending: Information for Providers

Article #

Article Release Date


Related CR Number

Related CR Release Date

Related CR Effective Date

Related CR Impl. Date
SE0565 10/25/2005 MMA – The Centers for Medicare & Medicaid Services (CMS) Recovery Audit Contract (RAC) Initiative
Revised: 10/24/2005



ERISA CD Book: $450 Medicare CD Book: $250
Holidays' Special -  ERISA CD & Medicare CD: $560

[More info on CD Books]       [Order CD Book]


OIG: Special Advisory Bulletin: Practices of Business Consultants [PDF]

The Office of Inspector General (OIG), Department of Health and Human Services, June, 2001


"Discouraging Compliance Efforts. Some consultants may make absolute or blanket statements that a client should not undertake certain compliance efforts (such as retrospective billing reviews) or cooperate with payor audits, regardless of the client’s circumstances. As reflected in the OIG’s compliance guidances,6 the OIG believes that voluntary compliance efforts, such as internal auditing and self-review, are important tools for doing business with the Federal health care programs. Left undetected and, therefore, unchecked and uncorrected, improper billing or other conduct may exacerbate fraud and abuse problems for a provider in the future." [page 5 of ]



Press Release      Complaint (pdf)



"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."



Medicare or My Health Plan (ERISA), Who Pays First?


Medicare Wants Money Back, My Health Plan Won't Pay


Am I in Trouble Again?



Medicare Secondary Payer: Improvements Needed to Enhance Debt, GAO Says (U.S. Government Accountability Office)

Excerpt: "Last year, employer-sponsored group health plans ... were responsible for most of the nearly $183 million in outstanding Medicare secondary payer (MSP) debt. MSP debts arise when Medicare inadvertently pays for services that are subsequently determined to be the financial responsibility of another. The Centers for Medicare & Medicaid Services ... administers Medicare with the assistance of about 50 contractors that, as part of their duties, are required to recover MSP debt."


Telecare Corp. v. Leavitt

(Fed. Cir. 2005)

"This case involves a dispute between Telecare Corp. (“Telecare”) and the government as to Telecare’s liability under the Medicare Secondary Payer statute, Social Security Act § 1862, codified at 42 U.S.C. § 1395y. The United States District Court for the Northern District of California held that Telecare was liable as a secondary payer. We affirm.




Therefore, we hold that the statute allows the United States to initiate an action against any employer that “sponsors or contributes to a group health plan,” where the group health plan “make[s] payment with respect to the same item or service (or any portion thereof) under a primary plan.” Such a construction gives reasonable meaning and effect to all the words in the statute, and is to be preferred over Telecare’s proposed interpretation, which would render parts of the statute inoperative. Telecare sponsors and contributes to the group health plan, and under the plain language of the statute it cannot prevail." "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.)






CMS: What Physicians and Other Suppliers Should Know About Medicare Overpayments - A two sided tri-fold brochure (August 2004) (PDF format 19Mb)


"Physician Disagreement with the Overpayment

The physician has the right to appeal the decision if he or she disagrees with the overpayment. Effective with Joint Signature Memorandum #255, dated June 3, 2004, recoupment will cease as a result of a demand letter if: (a) the first recoupment action occurred after December 8, 2003, and (b) a first level appeal has been received."


"What is an Overpayment?

Overpayments are Medicare funds a provider or beneficiary has received in excess of amounts due and payable under the Medicare statute and regulations. Once a determination of overpayment has been made, the amount of the overpayment is a debt owed to the Federal Government.  Federal law requires CMS to seek recovery of overpayments, regardless of how an overpayment is identified or caused......."



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."



"(g) Recovery from parties that receive third party payments. CMS has a right of action to recover its payments from any entity, including a beneficiary, provider, supplier, physician, attorney, State agency or private insurer that has received a third party payment.


Medicare Wants Money Back from You!!!

$134 Million This Time






  1. Medicare requested money back as CMS Medicare overpayment enforcement from providers, healthcare plans, but my healthcare plan policy, TPA agreement and PPO agreement are confusing and conflicting if we would comply with CMS requests, such as timely filing or payment provisions and ERISA plan fiduciary obligations, what should we do?

  2. If Medicare mistakenly paid primary several years ago, who should do what and what's time requirement for the employers, TPA's, healthcare providers?

  3. What party is responsible for making timely report of a possible Medicare overpayment?

  4. As a health plan or an employer, what should we do right away if Medicare has mistakenly paid primary and we just learned about it?

  5. As a provider, participating or nonparticipating with Medicare or PPO, Medicare now wants money back from us for the claims paid several years ago as CMS Medicare secondary payer enforcement, but my patient's health plan won't accept our claims citing timely filing violation, and our patients are nowhere to be found or our patients blamed on us for this mess, no one to send the claims and no one is willing to pay us, what should we do?


Headache + Frustration???


Am I in Trouble Again?



More info is coming








E-mail Your Questions to



1.      ERISA Regulates and Governs ERISA Claim Denials and Disputes

2.      Up to 80% of health-care claims or 60% of health expenditures in the U. S., Are ERISA Claims

3.     ERISA Governs Approximately 6 Million Private Health And Welfare Plans. These Plans Cover Approximately 150 Million Workers And Their Dependents And Hold Assets Of More Than $4.6 Trillion

4.     "In 2001, 32.2 percent of the elderly had employment-based health insurance coverage in addition to Medicare, up from 28.7 percent in 1987." (page 2) (Facts from EBRI: Health Insurance and the Elderly (PDF) - Employee Benefit Research Institute)

5.     CMS MSP FAQ from, pdf, 10 pages:                   
MSP Recoveries/Debt-Related Issues

6.     [CITE: 42USC1395y (b)(2)(3) ] TITLE 42--THE PUBLIC HEALTH AND WELFARE,  (3) Enforcement: (A) Private cause of action for "Double Damages" + (B) "an excise tax" + (C) "up to $5,000 Penalty/Violation" = (2X$+IR$+$5K)

7.     CFR Title 42, Volume 2 (Code of Federal Regulations)


TEXT PDF 411.21 Definitions.
TEXT PDF 411.24 Recovery of conditional payments.
TEXT PDF 411.25 Third party payer's notice of mistaken Medicare primary payment.
TEXT PDF 411.100 Basis and scope.
TEXT PDF 411.101 Definitions.
TEXT PDF 411.102 Basic prohibitions and requirements.
TEXT PDF 411.103 Prohibition against financial and other incentives.
TEXT PDF 411.104 Current employment status.
TEXT PDF 411.106 Aggregation rules.
TEXT PDF 411.108 Taking into account entitlement to Medicare.
TEXT PDF 411.110 Basis for determination of nonconformance.
TEXT PDF 411.112 Documentation of conformance.
TEXT PDF 411.114 Determination of nonconformance.
TEXT PDF 411.115 Notice of determination of nonconformance.
TEXT PDF 411.120 Appeals.
TEXT PDF 411.121 Hearing procedures.
TEXT PDF 411.122 Hearing officer's decision.
TEXT PDF 411.124 Administrator's review of hearing decision.

Medicare Wants Money Back from You!!!

$134 Million This Time


Medicare Secondary Payer (CMS)

Precedence of Federal Law

Federal law takes precedence over State law and private contracts. Thus, for the categories of people described in the regulations discussed below, Medicare is the secondary payer regardless of state law or plan provisions. These Federal requirements are found in Section 1862(b) of the Social Security Act {42 USC Section 1395y(b)(5)}. Applicable regulations are found at 42 CFR Part 411 (1990).

More information on MSP laws and regulations is available through the CMS Laws and Regulations Portal.

Responsibilities of Beneficiaries Under MSP

As a beneficiary, we advise you to:


Respond to Initial Enrollment Questionnaire (IEQ) and MSP claims development letters in a timely manner to ensure correct payment of your Medicare claims,


Be aware that changes in employment, including retirement and changes in health insurance companies may affect your claims payment,


When you receive health care services, tell your doctor and other providers and the Coordination of Benefits (COB) Contractor about any changes in your health insurance due to your or your spouse’s current employment or coverage changes,


Contact the COB Contractor if you take legal action or an attorney takes legal action on your behalf for a medical claim,


Contact the COB Contractor if you are involved in an automobile accident, and


Contact the COB Contractor if you are involved in a workers’ compensation case.

Responsibilities of Providers Under MSP

As a Part A institutional provider (i.e. hospitals), you should:


Obtain billing information prior to providing hospital services. It is recommended that you use the Centers for Medicare & Medicaid Services’ (CMS’) questionnaire, or a questionnaire that asks similar types of questions; and


Submit any MSP information to the intermediary using condition and occurrence codes on the claim.

As a Part B provider (i.e. physicians and suppliers)


Follow the proper claim rules to obtain MSP information such as group health coverage through employment or non-group health coverage resulting from an injury or illness;


Inquire with the beneficiary at the time of the visit if he/she is taking legal action in conjunction with the services performed; and,


Submit an Explanation of Benefits (EOB) form with all appropriate MSP information to the designated carrier. If submitting an electronic claim, provide the necessary fields, loops, and segments needed to process an MSP claim.

Responsibilities of Employers Under MSP

As an employer, you must:


Assure that your plans identify those individuals to whom the MSP requirement applies;


Assure that your plans provide for proper primary payments where by law Medicare is the secondary payer;


Assure that your plans do not discriminate against employees and employees’ spouses age 65 or over, people who suffer from permanent kidney failure, and disabled Medicare beneficiaries for whom Medicare is secondary payer; and,


Accurately complete and submit Data Match reports timely on identified employees.

Group Health Plans (GHP)

An employer cannot offer, subsidize, or be involved in the arrangement of a Medicare supplement policy where the law makes Medicare the secondary payer. It is considered a group health plan when an individual has health care coverage through their or their spouse’s employment. Even if the employer does not contribute to the premium, but merely collects it and forwards it to the appropriate individual’s insurance company, the GHP policy is the primary payer to Medicare.

Responsibilities of Attorneys Under MSP

As an Attorney, you must:


Immediately, upon taking a case, that involves a Medicare beneficiary, inform the COB Contractor about a potential liability lawsuit, and


Contact the assigned lead contractor regarding Medicare’s interest in a liability, auto/no-fault, or workers’ compensation lawsuit.

Responsibilities of Insurers Under MSP

As a GHP insurer, you must:


Report to the COB Contractor when you are primary to Medicare (i.e. 411.25).

As a Non-GHP Auto/Liability Insurer, you must:


Contact the COB Contractor immediately when the individual you insure is a Medicare beneficiary.

Medicare Secondary Payer (MSP) Claims Investigation

Effective January 8, 2001, the COB Contractor assumed responsibility for virtually all initial MSP development activities formerly performed by Medicare intermediaries and carriers. This means the COB Contractor is charged with ensuring the accuracy and timely update of data populated on Medicare’s eligibility database regarding other health insurance that is primary to Medicare. The COB Contractor also handles MSP-related inquiries, including those seeking general MSP information, but not those related to specific claims or recoveries.

The COB Contractor is primarily an information gathering entity. A variety of methods and programs are used to identify situations in which Medicare beneficiaries have other health insurance that is primary to Medicare:


More from CMS:  Medicare Secondary Payer (CMS)


CMS: What Physicians and Other Suppliers Should Know About Medicare Overpayments - A two sided tri-fold brochure (August 2004) (PDF format 19Mb)


DOL Advisory Opinion 93-23a

DOL Logo PWBA Office of Regulations and Interpretations


Advisory Opinion

September 3, 1993

Frederick D. Hunt, Jr., President
Society of Professional Benefit Administrators
Two Wisconsin Circle, Suite 670
Chevy Chase, MD 20815-7003


Dear Mr. Hunt:

This is in response to your request on behalf of your members for the Department of Labor's (the Department's) views on the application of the fiduciary responsibility provisions of Title I of the Employee Retirement Income Security Act of 1974, as amended (ERISA), 29 U.S.C. §1001 et. seq.. Specifically, you have raised a number of issues with respect to claims submitted to ERISA-covered employee benefit plans, pursuant to the Medicare Secondary Payer provisions of Title XVIII of the Social Security Act, 42 U.S.C. §1395y(b) (MSP statute), for recovery of mistaken primary payments made by Medicare.





42CFR411.24(l)(2)(ii) Exceptions:

"(ii) CMS will not recover from providers or suppliers that are in compliance with the requirements of Sec. 489.20 of this chapter and can show that the reason they failed to file a proper claim is that the beneficiary, or someone acting on his or her behalf, failed to give, or gave erroneous, information regarding coverage that is primary to Medicare."


Am I in Trouble Again?


[CITE: 42USC1395y (b)(2)(3) ] TITLE 42--THE PUBLIC HEALTH AND WELFARE,  (3) Enforcement: (A) Private cause of action for "Double Damages" + (B) "an excise tax" + (C) "up to $5,000 Penalty/Violation" = (2X$+IR$+$5K)


                       "CHAPTER 7--SOCIAL SECURITY


                    Part D--Miscellaneous Provisions

Sec. 1395y. Exclusions from coverage and medicare as secondary

 (3) Enforcement

        (A) Private cause of action

            There is established a private cause of action for damages
        (which shall be in an amount double the amount otherwise
        provided) in the case of a primary plan which fails to provide
        for primary payment (or appropriate reimbursement) in            accordance with such paragraphs (1) and (2)(A).

        (B) Reference to excise tax with respect to nonconforming group
                health plans

            For provision imposing an excise tax with respect to
        nonconforming group health plans, see section 5000 of the
        Internal Revenue Code of 1986.

        (C) Prohibition of financial incentives not to enroll in a group
                health plan or a large group health plan

            It is unlawful for an employer or other entity to offer any
        financial or other incentive for an individual entitled to
        benefits under this subchapter not to enroll (or to terminate
        enrollment) under a group health plan or a large group health
        plan which would (in the case of such enrollment) be a primary
        plan (as defined in paragraph (2)(A)). Any entity that violates
        the previous sentence is subject to a civil money penalty of not
        to exceed $5,000 for each such violation. The provisions of
        section 1320a-7a of this title (other than subsections (a) and
        (b)) shall apply to a civil money penalty under the previous
        sentence in the same manner as such provisions apply to a
        penalty or proceeding under section 1320a-7a(a) of this title."



CMS 2005 Transmittals
91 kb R28MSP 4/8/2005 PUB 100-05 Working Aged Exception for Small Employers in Multi-Employer Group Health Plans (GHPs) 5/20/2005 3768 - "Overpayment" Refund Request Response & Appeals



E-mail Your Questions to


"Failure of Imagination" Again?




NASA identifies foam flaw that killed astronauts (Reuters)


Jin Zhou Identifies "ERISA Failure" That Killed U.S. Healthcare



ERISA Failure Syndrome

U.S. Healthcare Crisis Trilogy

(Copyright © 2004 by Jin Zhou,


Medical Killing
Medical Inflation
Insurance Robbery

Read Making a Killing










American Job ExportING!

Mass layoffs up in January 2004

Weirton Steel cancels 10,000

GM: $67.5 billion in 2003

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


Healthcare Disaster at Fault Verdict Index:

U.S. Government 30%

U.S. Employers & Insurers 30%

Healthcare Providers 30%

Consumers 10%

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


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

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

  2. Rising Healthcare Costs Have Many Implications (Indirect)


Rx-1  $$$$$$$$$ERISA$$$$$$$$$$  Rx-2


The Root of U. S. Healthcare Crisis

Jin Zhou,


The Hearing at Senate Committee on Finance on 3-3-04, [View Video or Transcript (PDF) (]  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"!




"Failure of Imagination" Again?
(Copyright © 2004 by Jin Zhou,




Rx-1  $$$$$$$$$ERISA$$$$$$$$$$  Rx-2


ASO+HMO+PPO-SPD=$1.8 Trillion/Y US Healthcare Crisis




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
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".


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   


The United States General Accounting Office


Growing Challenges Point to Need for
Fundamental Reform


January 13, 2004


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


The External Review of Hospital Quality:

 Holding the Reviewers Accountable [pdf]


Department of Health and Human Services





The External Review of Hospital Quality


Holding the Reviewers Accountable



 HHS Logo


Inspector General

JULY 1999 OEI-01-97-00053


Birthday Sept. 2,


Happy or Sad 30th Birthday To ERISA?

(Copyright © 2004 by Jin Zhou,

Sept. 2, 2004

On Sept. 2, 1974, exactly 30 years ago today, ERISA, The Employee Retirement Income Security Act, was signed into law by President Gerald R. Ford. The congressional intent in enacting ERISA was to protect employees in pension and welfare plans, to provide uniform federal protections in response to the failure of the Studebaker Co. in December 1963, with thousands of long-service employees cheated out off their promised pensions, and to preempt any state laws when the employees pension and welfare benefits were threatened. 30 years later, ERISA Failure in its compliance and enforcement left thousands of retirees without medical benefits, and resulted in a skyrocketing national healthcare expenditure explosion with 45 million uninsured and a possible national pension bailout.

ERISA Failure Syndrome

U.S. Healthcare Crisis Trilogy


Jin Zhou Identifies "ERISA Failure" That Killed U.S. Healthcare

"Failure of Imagination" Again?





ERISA Celebrates 30th Anniversary As Trouble Brews For the Pension Insurance Program (Spencer Benefits Reports)

Excerpt: "The seed for ERISA was planted with the failure of the Studebaker Company in December 1963, leaving thousands of long-service employees without their promised pensions."

The Economic Downturn and Changes in Health Insurance Coverage, 2000-2003, (Kaiser Commission on Medicaid and the Uninsured)

 Other Resources Icon Executive Summary (.pdf)    Reports and Studies Icon Report (.pdf)


The number of uninsured Americans under age 65 increased by 5.1million between 2000-2003 largely driven by continuing declines in employer sponsored insurance. ....."

The Supreme Court and Employee Health Insurance (FindLaw's Writ - Sebok)

"What Americans generally don't know, however, is that this issue isn't restricted to the Congress or the Executive. To the contrary, the U.S. Supreme Court has been nationalizing one important aspect of health care in this country: the administration of medical health insurance offered by employers to their employees.


This creeping nationalization has been achieved slowly and surely by the expansion of the court's interpretation of an important federal law: the Employee Retirement Income Security Act (ERISA)."

Private Plans Costing More for Medicare (The New York Times)

"The Medicare Payment Advisory Commission, an independent federal panel, says in a report to Congress that Medicare is paying private plans an average of 107 percent of what it would cost to cover their patients under the traditional fee-for-service program. Payments were as high as 116 percent of the traditional Medicare cost in some cities and 123 percent in rural counties."

Inquiry on Medicare Finds Improper Limits on Choices of Health Care Providers (The New York Times; one-time registration required)

Excerpt: "Federal investigators said Monday that the Bush administration had improperly allowed some private health plans to limit Medicare patients' choice of health care providers, including doctors, nursing homes and home care agencies."

Medicare Demonstration PPOs: Financial and Other Advantages for Plans, Few Advantages for Beneficiaries GAO-04-960, September 27, 2004

Abstract    Highlights-PDF    PDF 



Medicare New Policy: Medical Necessity in Emergency/Critical Care


On November 5th, CMS issued a modification to the Medicare Integrity Manual for "Payment for Emergency Medical Treatment and Labor Act (EMTALA) and new policy in making emergency room medical decision terminations", and "Instructs that for an item or service provided by a hospital or critical access hospital pursuant to section 1867of the Social Security Act (EMTALA) on or after January 1, 2004, FIs must make determinations of whether the item or service is reasonable and necessary on the basis of information available to the treating physician or practitioner (including the patient’s presenting symptoms or complaint) at the time the item or service was ordered or furnished by the physician or practitioner (and not only on the patient’s principal diagnosis). The frequency with which an item or service is provided to the patient before or after the time of the service shall not be a consideration."


CMS Manual System Department of Health & Human Services (DHHS)


Pub. 100-08 Medicare Program Integrity Centers for Medicare & Medicaid Services (CMS) Transmittal 86 Date: NOVEMBER 5, 2005 CHANGE REQUESTS 3437


Text of HHS Semiannual Regulatory Agenda (PDF) (Department of Health & Human Services) 12/13/2004



CMS News on Wheelchair and Medical Necessity




“We are working toward completing our overhaul of the Medicare claims appeals system by October 1, 2005 to better serve Medicare beneficiaries, providers, physicians, and other health care providers.”

"Other steps that CMS is taking as part of its comprehensive overhaul of Medicare claims appeals include:
bullet 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.
bullet Developing a new appeal-specific data system that will allow authorized users to track  individual appeals in real time.
bullet 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
bullet 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??$



Age Estimates in the National Health Accounts (pdf), Sean P. Keehan, Helen C. Lazenby, Mark A. Zezza, and Aaron C. Catlin



RenCare Ltd vs. Humana Health Pln TX

(5th Cir. 12/30/2004)


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


Revision to Appeals Timeframes and Amounts
940A Mediation Process for Local Coverage Determinations
952 Revisions to Reassignment Provisions


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

US Map


CERT  Reports

Improper Medicare Fee-For-Service Payments Report and Update Archive


2004 Improper Medicare Fee-For-Service Payments Report


Short Report (859 KB)


Long Report (1.04 MB)
Long Report Appendix (2.29 MB)


First Update Report (356 KB)


Second Update Report(369 KB)


2003 Improper Medicare Fee-For-Service Payments Report


Short Report

(923 KB)


Long Report

(2.29 MB)



CFR Titles on GPO Access (Code of Federal Regulations)

2003 CFR Title 42, Volume 2 (Code of Federal Regulations)


Social Security Act


October 2004 QPU - Physicians (CMS)

The Medicare Prescription Drug, Improvement and Modernization Act of 2003


Paperwork Reduction Act of 1995


National Coverage Analyses


National Coverage Determinations


Laboratory NCDs Only


Medicare Modernizaton Act (MMA) Coverage Flowchart


Summary of MMA Changes to the NCD Process


Coverage Regulations


COB Web Site Update


Medicare Secondary Claim Development Questionnaire


Coordination of Benefit & You

Insurers' Frequently Asked Questions


Beneficiary and Advocate Services Welcome

Provider Services Welcome

Employer Services Welcome

Attorney Services Welcome

Insurer Services Welcome

Coordination of Benefits Agreement
Workers' Compensation Welcome

Medicare Secondary Payer and You
Medicare Initial Enrollment Questionnaire (IEQ)






TRICARE Military Health System


Federal Employees Health Benefit Plan




Uninsured Reached

45 Million in 2003
US Census Press Releases

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


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

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

(10 years on the web)

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


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

US 2001: slump or recession? - Jul. 30, 2004


Yahoo News (press release)


Book: the State of Working America 2004/2005 (Economic Policy Institute)

Read an excerpt

Read the news release Adobe Acrobat (PDF)

Executive Summary







Pension Bailout Called Possibility (Bloomberg News via Chicago Tribune)



U.S. Expresses Concern About UAL Pensions (Reuters via The New York Times (one-time registration required))



Pensions on a Precipice: What Could Happen If UAL Offloads Its Retirement Plan on the Feds? (BusinessWeek Online)


Greenspan Issues Warning on Retirement Benefits (The New York Times)

"JACKSON HOLE, Wy., Aug. 27 — The chairman of the Federal Reserve, Alan Greenspan, warned today that the Federal government might have to scale back promises to the elderly in programs like Social Security and Medicare."


ICI Statement on Disclosure to Plan Sponsors and Participants before the ERISA Advisory Council (Investment Company Institute (ICI))


Testimony before the ERISA Advisory Council on Fee and Related Disclosures to Participants (American Society of Pension Actuaries)





Health Plans for Retirees Face Big Cuts (Business First of Buffalo via bizjournals)



Washington Put on Pensions Alert (The Financial Times; one-time registration required)




Opinion: General Motor' s Chief Says Health Care Needs Bipartisanship (AP via Council for Affordable Health Insurance)


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













PBGC: When Will the Cash Run Out? (

PBGC could exhaust its cash and investments by 2020, according to projections from our cash flow model, the first such model to be publicly available.

Download PDF version

Download Summary Only (PDF)




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