|
|
|
|
2006
Reimbursement Seminars
Problem Oriented
ERISA & Medicare Claims
&
New IL
WC Laws
Click above for
2006 Seminars |
|
Seminars - ERISA, New Federal Laws
for Health-care Claim Denial & Appeals
Illinois
CALL: 1-630-736-2974 |
|
2005
Schedules
In
IL
Details & Registration
PDF/Fax verion of Registration Form
Online
Registration
Advanced
Certification
Programs
|
Jan. 21, 2005, Friday
9 a.m.-5 p.m.
Feb. 18, 2005, Friday
9 a.m.-5 p.m.
Mar. 18, 2005, Friday
9 a.m.-5 p.m. (Changed to SD from IL)
Apr. 15, 2005, Friday
9 a.m.-5 p.m.
May 20, 2005, Friday
9 a.m.-5 p.m.
Jun. 24, 2005, Friday
9 a.m.-5 p.m.
Jul.
22, 2005, Friday
9 a.m.-5 p.m.
Aug. 19, 2005, Friday
9 a.m.-5 p.m.
Sep. 30, 2005, Friday
9 a.m.-5 p.m.
Oct.
21, 2005, Friday
9 a.m.-5 p.m.
Dec.
16, 2005, Friday
9 a.m.-5 p.m.
|
Pre-registration |
$225
|
|
(checks for pre-registration must be
postmarked two weeks prior to the seminar) |
|
|
Late registration |
$250 |
|
Registration and payment at the
door |
$275 |
|
Additional Staff from Same Office |
$150 |
|
Previous Attendees |
$150 |
|
VIP's |
$0.00 |
|
Where |
Vision MRI & CT Of Oak Brook
(In the
Same Building of
Oak
Brook Surgical Center,
Driving Directions)
2425 W. 22nd Street, Suite #205
Oak Brook, Illinois 60523
(click
it for Map & direction)
(Turn South at Tower Drive from W.
22nd St., Under Oak Brook Water Tower)
|
|
Driving Directions
 |
|
For Fax Registration
Click here to Download PDF/Fax verion of Registration Form
For Online Registration or Order
Click here to enter our secured online registration page
Please Specify the Date of Your Seminar on
Registration Form
Tape or any forms of digital recording of seminar are not allowed
Copyright © 2001-2009
Seminar Schedules
in IL,
NC, PA, VA,
OH, Teleconference
We now
offer post-seminar teleconference
for staff training at $190/hour.
Fax To:
(630) 736-1439
A confirmation will be given by fax
CALL: 1-630-736-2974
E-mail Your Questions to
ERISAclaim@aol.com
|
|
Our New ERISA
Program Agenda
Seminar Schedules
in IL,
NC, PA, VA,
OH, Teleconference
950,000
Physicians Agreed to Do ERISA Appeals in
Settlement of Physician
Class-Action Lawsuits
"Aetna
and CIGNA Settlement Secrets"
"Talking
Points"
What You
Should Know about Filing Your Health Benefits Claim
Medicare & ERISA,
Medicare Secondary Payer (CMS)
and
Debts
"Overpayment" Recovery.
You will learn from our
ERISA
demystified
educational seminars, backed with
turn-key
tools and solutions:
1. The basics of ERISA, definition, how to identify ERISA plans, how
to understand basic terms and definitions of ERISA law and regulations
for health-care claim processing and claim appeals;
2. How to get paid timely for what
you legally entitled to or process ERISA health care claims with savings
in accordance with ERISA claim regulation, Final Rule, and Summary Plan Description
(SPD) Final Rule, ERISA Frequent Asked Questions from DOL as we outlined
in above "ERISA POWER GUIDES";
3. ERISA claim regulation or your
state law, which law governs your concerns and disputes, with respect to
coverage, medical necessity and billing & coding, dispute resolution and
appeal process.
ü
Learn the
New Federal (ERISA) Claims Regulations and how they protect and
empower you during claim disputes and WHY
ERISA, a federal law has been kept
secret for 28 years
Ø
Learn What ERISA is
really about and how it regulates
80% of your health-care claims
Ø
Find out why you need a
new legal assignment of benefits,
Your License for Dispute & Appeals (Q-B2 & B3)
Ø
Find out how to properly
request for
full disclosure on pertinent plan documents (Q-B5, D8, D9, D10 & D11)
Ø
Find out what types of
federal penalties can be imposed on managed care plans that fail to
comply, federal protection against
Bundling & Down Coding,
UCR
&
Medical Necessity Denials
ü
Learn about the
Utilization Review Laws and how they can help fight against
improper, unfair
& noncompliant pre-certification and
medical necessity reviews
ü
Learn all about the NEW
ERISA claim APPEALS PROCESS
Ø
Claim denial is followed
by our ERISA compliant document disclosure request
Ø
Learn how to utilize our
automated appeal templates for specific denial letters
Ø
Learn how to do appeal
letters that focus on
federal laws that preempt state law
Ø
Learn how our
NEW ERISA
claim appeal process places the
burden of proof on the managed care plans, turning table around for
endless paper chase and stressful denial crisis!
Ø
AND more...
Results Nationwide
v
Maximal Reimbursement
through
ERISA Compliance
v
Crisis Turnaround through ERISA Compliance
v
Happy
Staff, Happy Patients
v
Increased Respect from the Insurance Industry and Self-funded ERISA
Plans
v
Devote More Time to Patient Care Instead of Claim Denial Crisis Care
|
|
Alert:
We will include one-hour coverage on New Medicare Appeal Process in each of
our ERISA Seminars
Starting from April 2005
Maximal Healthcare Claim Reimbursement
through ERISA Compliance
Educational Training Programs
For Every One Who Handles ERISA Healthcare Claims
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.....
(OIG: Special Advisory Bulletin: Practices of
Business Consultants)
Disclaimer
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
U.S. Health-care Crisis & ERISA Criminal Enforcement
Due to the
recent
demand from the
ERISA plans
and TPA's, we're pleased to announce that we also provide
educational and consulting services to
the ERISA plans, TPA's and managed
care organizations on
New
Federal Claim/ERISA Regulations and
Compliance, however we do not provide any services involving actual
claim dispute or legal advice for any legal matter or disputes.
|
2004
& 2003 Past Schedules |
Jan. 23, 2004, Friday
9 a.m.-5 p.m.
Feb 20,
2004, Friday
9 a.m.-5 p.m.
Mar 19,
2004, Friday
9 a.m.-5 p.m.
Apr 16,
2004, Friday
9 a.m.-5 p.m.
May 14, 2004, Friday
9 a.m.-5 p.m.
Jun 25, 2004, Friday
9 a.m.-5 p.m.
July 16,
2004, Friday
9 a.m.-5 p.m.
Aug
20 ,
2004, Friday
9 a.m.-5 p.m.
Sep.
23, 2004, Friday
6:00
p.m.-9:00 p.m.
(3Hr CME, Podiatrists Free, $30-$70 Specials,
Download Registration for Details)
Sep.
24, 2004, Friday
9 a.m.-5 p.m.
Oct.
08, 2004, Friday
9 a.m.-5 p.m.
Nov. 12, 2004, Friday
9 a.m.-5 p.m.
Nov. 18, 2004,Thu.
King of Prussia ~ PA
(Registration Form, PDF)
Dec. 17, 2004, Friday
9 a.m.-5 p.m.
Jan.
14, 2003, Tuesday, 9 a.m.-5 p.m.
Feb. 21, 2003, Friday, 9 a.m.-5 p.m.
March 21, 2003, Friday, 9 a.m.-5 p.m.
April 12-13,
Sat-Sun, Canton, Ohio
May 16,
2003, Friday, 9
a.m.-5 p.m.
June 13, 2003,
Friday, 9 a.m.-5 p.m.
July 18,
2003, Friday, 9 a.m.-5 p.m.
Sept. 19,
2003, Friday, 9
a.m.-5 p.m.
Oct. 11, 2003, Saturday, 9 a.m.-5 p.m.
Langhorne, PA
Oct. 17, 2003,
Friday, 9 a.m.-5 p.m.
Nov. 04,
2003, Thursday, 9 a.m.-4 p.m.
Akron, Ohio
Nov. 14,
2003, Friday, 9 a.m.-5 p.m.
Dec. 12,
2003, Friday, 9 a.m.-5 p.m.
April 20, 2002, Saturday, 9 a.m.-5 p.m.
May 17, 2002, Friday, 9 a.m.-5 p.m.
June 21, 2002, Friday, 9 a.m.-5 p.m.
July 26, 2002, Friday, 9 A.m.-5 P.m.
Sept. 27, 2002, Friday, 9 a.m.-5 p.m.
Oct. 25, 2002, Friday, 9 a.m.-5 p.m.
Nov. 22, 2002, Friday, 9 a.m.-5 p.m.
Dec. 13, 2002, Friday, 9 a.m.-5 p.m.
|
| |
|
CME -911 (for
Illinois)
Solve Your Managed Care Headaches
and
Get 8, 16, or *32 CME Credits
Before Your License Renewal Deadline: 07/31/2005 |
|
8/day HRS CME Approved through National University of
Health Sciences
*32 CME
by Special Arrangement only (8/day)
**for
CME Credits, Tuitions: $50 Additional/day
225 ILCS 60/20 Medical Practice
Act of 1987.
Administrative Rules Section
1285.110 Continuing Medical Education (CME) |
|
With New OIG Compliance
Recommendations
Medicare Documentation
for the Demonstration Project
 |
Our ERISA-Medicare
seminar will teach you exactly what to do when you are denied.
|
|
Our ERISA-Medicare
seminar will teach you the rules of the game so that you can
unlock your clinic’s full potential. |
|
Our ERISA-Medicare
seminar will bring light back into your practice, because you
will no longer be a helpless managed care victim. |
Friday July 22, 2005 9
AM-5 PM
Oak Brook, Illinois
or
We Can Come to Your
Office at Your Convenience
for Any Group of Ten or
More |
Title 29 U.S.C. § 1141 states:
"It shall be unlawful for any
person through the use of fraud, force, violence, or threat of
the use of force or violence, to restrain, coerce, intimidate,
or attempt to restrain, coerce, or intimidate any participant or
beneficiary for the purpose of interfering with or preventing
the exercise of any right to which he is or may become entitled
under the plan, this title, section 3001, or the Welfare and
Pension Plans Disclosure Act. Any person who willfully violates
this section shall be fined $10,000 or imprisoned for not more
than one year, or both. The amount of fine is governed by 18
U.S.C. § 3571. The U.S. Sentencing Guidelines address 29 U.S.C.
§ 1141 under the guidelines for "Fraud and Deceit" (U.S.S.G. §
2F1.1) or for "Extortion by Force or Threat of Injury or Serious
Damage (U.S.S.G. § 2B3.2)......"
"For example, Section 1141
would reach the use of deception directed
at misleading a welfare plan beneficiary as to the amount of
health benefits owed to the beneficiary under the terms of the
plan or at misleading a pension plan participant as to
the amount of retirement benefits to which he would become
entitled under the plan upon his retirement."
ERISA in the United States Code
|
|
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.
|
|
|
|
"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
|
|
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)
Excerpt: "Looking to
bring down soaring health-care costs anywhere they can, more
employers are scouring their health plans for fraud, abuse and
simple mistakes by employees or administrators.
.......The
number of requests for such audits jumped 50 percent last year,
Mr. Farley estimates."
Blue Cross and Blue Shield Association Announces New Strike
Force to Protect American Consumers from Fraud and Fight Rising
Costs (U.S.
Newswire, 4/19/2004)
"DETROIT, April 19 /U.S.
Newswire/ -- The Blue Cross and Blue Shield Association (BCBSA)
today announced a new Anti-Fraud Strike Force comprised of top
Blue Plan investigators that will work with the Federal Bureau
of Investigation (FBI) and other national, state and local law
enforcement agencies to fight major insurance fraud schemes that
rob consumers of millions of dollars annually. BCBSA President
and CEO Scott P. Serota announced the new initiative in a speech
to the Detroit Economic Club."
Clinton Township Firm Convicted of
Overbilling (Macomb
Daily)
"The case is somewhat
unusual in that a corporation was named as a criminal defendant
in the case,
but Kaiser said that is not unheard of since corporate law can
make a firm liable for criminal wrongdoing, and its principal
office holders in return are responsible for any judgments or
punishments the courts impose.
David Griem,
the defense attorney for Emergency Management who was also named
the principal to enter a guilty plea on its behalf,
also could not be reached for comment after the sentencing
hearing. In court, however, he turned over a check to the Blue
Cross insurance company officials in attendance and said the
company would pay the $5,000 court costs on time as well."
|
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"
|
|
Breaking News
|
Denials +
Recoupment =
Inflation +
Fraud or
Cost-Sharing?
Rx =
Compliant Denial & Appeals! |
|
Forbes.com: "Roughly one in seven Americans has
no health insurance. That hurts HCA Inc. (nyse:
HCA -
news
-
people), the largest U.S. hospital chain, which
last year wrote off $2.21 billion
of revenue because patients couldn't pay their
bills."
The American Hospital Association (AHA): "Hospitals today are faced with the challenge of managing their
limited resources, while continuing to deliver the highest standard of care.
According to health care experts, the cost of clinical
denials to individual healthcare organizations averages
$3.3 million
annually. However, many hospitals do not have the resources or the
expertise needed to avoid unpaid days at the end of admissions and lead the
denial-appeals processes."
Payments Go Under a Microscope (washingtonpost.com)
"MAMSI and CareFirst recoup overpayments to doctors by making
deductions from future reimbursements.
Doctors can appeal insurers' decisions.
But, in the end, they usually pay up, doctors and insurers agree."
Hospital Pricing and the Uninsured,
Glenn Melnick, Ph.D.,
"Price
Gouging"
(Subcommittee on Health
Hearing on the Uninsured,
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
|
The Most Powerful & only Seminar in the
U.S.
Focused
on Health Care
ERISA
Claim Denials & Appeals
Seminar Schedules
in IL,
NC, PA, VA,
OH, Teleconference
Call (630)-736-2974
FAX to (630) 736-1439
Only One Payment
from Your Denied Claims
May Pay off the Seminar or Book Itself!
Why Not Take Actions to Save 40% of Your Business & Headaches?
|
| |
|
Should
You Wait?
In
a letter from Republican
Congressional leader, John Boehner, to the
Secretary of Labor and
insurance/benefits
industry,
he states that "specifically,
we are concerned about provisions in the final rule that
go even further than the patients' rights
bills
passed by the Congress",
and he urged DOL to revise and delay the entire
claims regulation. |
|
Why ERISA Seminars for Health-care Providers??? |
-
Health-care claim denial problems have
fundamentally threatened health-care providers business survival;
-
Up to 1/3 health-care claims was completely denied,
rest of them partially and significantly denied. Up to
$500 billion were denied health-care claims in 2000.
-
$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.
-
ERISA regulates about 80% of health-care claims and
is never understood by health-care providers;
-
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;
-
New
Federal Claim Procedure, to be effective January 2002, 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;
-
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.
|
|
Where: |
Vision MRI & CT Of Oak Brook
2425 W. 22nd Street, Suite #105
Oak Brook, Illinois 60523
(click
it for Map & direction)
|
|
For Fax Registration
Click here to Download PDF/Fax verion of Registration Form
For Online Registration or Order
Click here to enter our secured online registration page
Please Specify the Date of Your Seminar on
Registration Form
Seminar Schedules
in IL,
NC, PA, VA,
OH, Teleconference
We now
offer post-seminar teleconference for staff training at $190/hour.
Due to the recent
demand from the
ERISA plans
and TPA's, we're pleased to announce that we also provide
educational and consulting services to the ERISA plans, TPA's and managed
care organizations on
New
Federal Claim/ERISA Regulations and Compliance, however we do not provide any services
involving actual claim dispute or legal advice for any legal matter or
disputes.
|
Only One Payment
from Your Denied Claims
May Pay off the Seminar or Book Itself!
Why Not Take Actions to Save 40% of Your Business & Headaches?
|
Column 1/Column 2 Correct
Coding Edits
(formerly Comprehensive/Component Edits)
Mutually Exclusive Edits |
|
|
Comprehensive Error Rate Testing (CERT) Program |
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
|
|
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"
|
|
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."
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. (Adobe Acrobat - 708K)
Strengthening Ethical Cultures: The Emerging Role of
Compliance Programs and Officers in Managed Care Organizations
(Ernst
& Young)
|
|
ERISAclaim.com provides unique
and unprecedented seminars on health-care ERISA claims denials and appeals resolution services
for healthcare
providers, physicians, clinics and hospitals. We concentrate on educating
and assisting healthcare providers to become more aware of the most
mystifying federal law, ERISA for past
28 years, and
new federal ERISA regulations for claims
procedures, to be effective January 2002. Our goal is to help you become more effective at prevailing on
improperly denied health care ERISA claims after traditional and
conventional appeal procedures have failed. We will demystify the
complicated federal law, ERISA, which governs most of about 80% of
health-care claims.
Health-care providers need a practical and meaningful way to protect their
rights as well as their patient's rights as originally intended by Congress
in 1974 with
Employee Retirement Income Security Act (ERISA).
|
|
Associations for Physicians, Hospitals, Health-care Providers
We are willing to work with any associations with your co-sponsorship
and significant discount for tuitions and reference books. You may
e-mail or
telephone for more details. |
|
| |
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Codified in Title 29 of the
Code of Federal Regulations:
Regulations
Selected links:
2520.102-3 Contents of summary plan description.
2560.503-1 Claims procedure. |
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ERISA Laws/Rules
|
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ERISA in US CODE
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ERISA &
Health Claim |
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What Is
ERISA and How Does It Affect Patient Rights?
"ERISA was enacted in 1974 to protect the pension and welfare
benefits that employers provide their workers. It currently
covers about 2.5 million health plans and 125 million workers,
retirees, and dependents." |
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ERISA v State Laws |
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$10,600 ERISA Claim
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| 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.
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$37,350 ERISA Claim
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| 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.
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Former uninsured patients alleged predatory collections
Chicagobusiness.com
Fraud Recovery and Prevention Efforts Net Over $7.5 Million
FAQ/Glossary, Member Services, Preferred Health Network, PHN Online,(
CareFirst BlueChoice, Inc.)
DOL ERISA Talking Points
(BCBSCNY)
BCBS 2004
Edu Programs (pdf)
BCBS2003 Edu Programs (pdf)
Washington Post Examines Health Plans' Increased Scrutiny of
Healthcare Providers' Claims (KaiserNetwork.org)
ABCNEWS.com : Huge Medical Insurance Scam Alleged
"Rarely does the FBI discuss an ongoing investigation. But the
agency made an exception because this scam is so big. Insurance
companies have already been hit with half a billion dollars in
claims."
CNN.com -Transcripts:
A New Plan to Fight Terrorism? A look at Healthcare Fraud
Rent a Patient - Fraud Scheme
(BCBSAL)
KSAT.com - Health - 'Rent-A-Patient' Fraud Under Investigation
"UnitedHealth Group alone said it's told the FBI about 300
allegedly fraudulent Southern California centers."
State of Wisconsin - DOJ News Release
Lautenschlager Announces Public Alert on "Rent a Patient"
Insurance Scams Victimizing Wisconsin Citizens and Businesses
Outpatient surgery centers probed for fraud
(San Jose Mercury News, CA)
'Rent-A-Patient' Fraud Under Investigation
(NBC4.TV, CA)
New Boston podiatrists accused of insurance fraud (AP Wire |
03/11/2004)
TWO ACCUSED IN NEW BOSTON MEDICAL SCAM
(Tyler Morning Telegraph)
USDOJ: Deputy Attorney General: Publications and Documents - -
Health Care Fraud Report Fiscal Year 1998
Payments Go Under a Microscope (washingtonpost.com)
CMS: Comprehensive Error Rate Testing (CERT) Program
(January 15 , 2004)
RECOVERY room
(MLive.com)
USATODAY.com - Hospitals sock uninsured with much bigger bills
A Booster Shot for Uninsured
"Illinois hospitals are hammering out a plan to provide
free or discounted care to the uninsured"
Hospital group examines plan for free care ( Chicagobusiness.com)
""Aggressive collection tactics with uninsured
patients cost a non-profit hospital in Urbana its tax-exempt
status last month. Illinois Attorney General Lisa Madigan is
investigating hospitals’ dealings with the uninsured, and a
Chicago alderman is talking about revoking tax breaks for
hospitals that limit charity care."
Doctor 'scorecards' are proposed (The Wall Street
Journal)
Bureau of Justice Statistics Medical Malpractice Trials and
Verdicts in Large Counties, 2001 (Acrobat
file) (Press
release) |
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