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Moukawsher & Walsh, LLC
Pension and Employee Benefit Law

SPD's for NJ State


for employees and retirees

January 2003  (pdf)


U.S. Healthcare Crisis Turnaround?

U.S. A.

Drs. & Hospitals Employers

$1.0 Trillion / Year

$$$ ERISA $$$

50% Savings

The Only Company with Compliant Solutions for All of You

Rx-1  $$$$$$$$$ERISA$$$$$$$$$$  Rx-2
US Supreme Court Visits

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

New Federal Health Claims & Appeals Laws & Regulations

for 193 Million Americans

Effective 09-23-2010

©2010, Jin Zhou,

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]



Employee Retirement Income Security Act — ERISA


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)


We Are Seeking New Strategic Partners


We Are Seeking New Strategic Partners is seeking for strategic alliance with new business partners.

With a business market at estimated $600 billion to $700 billion and U. S. healthcare expenditure at estimated $1.8 trillion for 2004, the health-care delivery and workers' health insurance business opportunities and challenges have exploded from not only healthcare claim reimbursement and denial management but also every American business survival line due to unsustainable health-care costs.

United States Supreme Court ruled unanimously in Aetna v. Davila on June 21, 2004 that Paramount and preemptive governing power and law for U. S. health-care quality and costs dispute and crisis is ERISA, Employee Retirement Income Security Act of 1974. is a new company with most comprehensive and unprecedented services and solutions for U. S. health-care crisis. We are seeking for new strategic alliance with new business partners with complimentary prospects and mutually win-win benefits.


we are the only company in the country with special understanding and practice of ERISA claim regulation, compliance and implementation in education, consulting, claims recovery, publication and U.S. health-care crisis ERISA resolutions. we researched and dissected every step of benefits claim and managed-care claim denial with ERISA diagnosis and compliant resolutions.


Please evaluate our business unique values and market niche, and contact us if you believe our business may compliment each other with unprecedented win-win benefits.


Seminar Alliance


If your business has long history or a broad base of health-care reimbursement seminars, and but you are facing some difficulties or less than anticipated results due to reckless managed-care denials, like everyone else in the country, or you would like to empower your seminar attendees with ERISA superpower productions, we would like to work with you to supplement or compliment you with ERISA claim regulation education for maximal reimbursement through compliance.


If your company or plan is seeking compliance education for third-party claim administrator, benefits consultant, and in-house benefits management but found ERISA claim regulation to be confusing and extremely difficult to understand, we would like to work with you to supplement or compliment with demystifying ERISA claim regulations for your claim fiduciaries, benefits managers and claim processes for maximum compliance and benefits containment.


We promote faithful compliance through fundamental understanding of ERISA claim regulation and streamlined claim appeal process for claim fiduciaries.

Please e-mail for more details


Reimbursement or Benefits Consulting Alliance


Maximal reimbursement through compliance or benefits appeal management under ERISA, regardless which segment you are consulting for, fundamental understanding of new ERISA claim regulation and practical mastering and implementation of ERISA claim regulation in most versatile managed-care environment will protect and secure your business bottom line through compliance, especially after Supreme Court reason ruling in Aetna v. Davila with possible "make-whole" relief remedies, health-care fraud and abuse prevention and litigations as well as escalating health-care costs crisis.


Bottom Line: maximal reimbursement through ERISA compliance and fraud and abuse prevention; benefits denial and appeal management with ERISA compliance to minimize fiduciary liabilities and losses in benefits costs control.


If your company is consulting for health-care providers or benefits plans and would like to expand or enhance your services to powerful and practical ERISA claim regulation compliance and implementation, we would like to work with you.


we are the only company in the country with special understanding and practice of ERISA claim regulation, compliance and implementation in education, consulting, claims recovery, publication and U.S. health-care crisis ERISA resolutions. we researched and dissected every step of benefits claim and managed-care claim denial with ERISA diagnosis and compliant resolutions.

Please e-mail for more details


Claims Recovery Alliance


As stated above, with our unique expertise and practical experience, we would like to work with you to compliment or to supplement you recovery services if you have significant accounts with hopeless results from ERISA plans or managed care plans.

Please e-mail for more details


Health-care Crisis Turnaround Initiatives and Solutions


If you are a plan sponsor or benefits consulting firm working diligently on practical solutions while health-care crisis is worsening with plan health benefits costs uncontrollably out-of-control for years, as entire nation is losing the battle and war in health-care crisis, we would like to work with you to find a new way out, an ERISA solution with unprecedented but compliant results.


We can't accomplish this without your participation. Our solution is based on fundamental research of every segment of health-care claim adjudications, managed-care principle, benefits design and administration as well as ERISA claim regulations and Supreme Court rulings.


Please e-mail for more details


Please note that we are not offering employment opportunity in this business alliance, this is a proposal for strategic alliance and networking.


OIG: Special Advisory Bulletin: Practices of Business Consultants [PDF] []
The Office of Inspector General (OIG), Department of Health and Human Services
, June, 2001


Conclusion or Confusion?

© 2005, Jin Zhou,


"Medicare Appeals Specialist" and "ERISA Claims Specialist" will be the crown of US healthcare reimbursement. - 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.  ERISA Certification Programs for Cost-Saving & Reimbursement by Compliance


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,, 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


Former Process


Medicare Claims Processing Manual

Chapter 29 - Appeals of Claims Decisions

CMS Transmittal - R146OTN


New Medicare Appeal

 Strategies for

Reimbursement Success


  1. Documentation

  2. Fraud And Abuse

  3. Medical Review

  4. National Correct Coding Initiative (NCCI)

  5. more

New Medicare Appeal Laws  Intertwined with($183 million/y)

ERISA Claims Laws



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

Fraud Health Care Cards
"New Strike Force"

Medical Fraud Every Day?

Appeal or Re-Bill After Denial?


No Re-Billing!!!

Claim Appeal or Sentencing Appeal?

Your Choice
Maximal Reimbursement
through ERISA Appeal &

Fraud Prevention and Compliance

ERISA Power Guides
by, Copyright © 2004)

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
New @ elaws

Health Benefits Advisor

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


Health Benefits Laws By State
(Interactive Tools From

Health Insurance Mandates in the States, 2004: a State-by-State Breakdown ... (PDF)
(Council for Affordable Health Insurance)


Consumer Guides for Health Insurance in Every State and the District of Columbia (Georgetown University)

View a 5-minute clip

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

To Avoid "John Q.


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

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

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

Payments Go Under a Microscope ( "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." - Hospitals Sock Uninsured with Much Bigger Bills

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


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"!



A New Diagnosis & Solution:

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

HMO Crisis Is Really An ERISA Crisis!

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

Costly Managed Care & Medical Malpractice Lawsuits
American Job Export!


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

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


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


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".



$10,600 ERISA Claim

Recent Federal Court Ruling in a Case with $10,600 medical claim, insurance Co. refused to pay, provider made numerous demand for payment in almost one year, but no appeals filed, the court dismissed the lawsuit because provider failed to exhaust administrative remedy, as required under ERISA, by filing ERISAclaim appeals.  This situation is so popular in health-care community.



$37,350 ERISA Claim

Health-care provider alleged medical claims submitted to Aetna for reimbursement, Aetna asserted no receipt of medical claims, no written denials.  Health-care provider failed to present proof of claim submission, claim denial and ERISA claim appeals. This case was dismissed. ERISA health-care claims are handled in federal court, state law is generally not applicable.




Statutes (United States Code) 
ERISA - Title 29, Chapter 18. 

        Selected links:

Sec. 1002.

Sec. 1003.

Sec. 1022.
Summary plan description
Sec. 1104.
Fiduciary duties

Sec. 1140.
Interference with protected rights

Sec. 1141.
Coercive interference
part 7
group health plan requirements



Code of Federal Regulations

Codified in Title 29 of the Code of Federal Regulations:


        Selected links:

2520.102-3 Contents of summary plan description.

Claims procedure.


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