|
|
|
(OIG: Special Advisory Bulletin: Practices of
Business Consultants)
|
Important Links and Resources |
|
Managed-Care Nightmares?
What Does Unanimous
US Supreme Court Say?
Do You Have Problems with
Health-Care Claims with Employer-Sponsored Health Plans, Claim Denials
and Delays with Providers, and Claim Processing, Denial Management and
Cost Containment with Health Plans?
If yes, we have answers
for all of you: information and guidance from US Supreme Court, Federal
Government on federal laws and regulations to help you and protect you.
Managed-Care Nightmares? What Does
the 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 -
Supreme Court Managed Care ERISA Watch
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."
|
'External Review' of Medical Claim Denials Is Now the Law
of the Land Nearly Nationwide (Modern
Healthcare via The Foundation for Taxpayer & Consumer Rights)
Excerpt: "[N]ow that the dust
has settled in the wake of last year's U.S. Supreme Court
decision preventing millions of patients from suing their HMOs
for medical negligence, some legal experts say the practical
effects of the controversial ruling may not be all that
substantial-largely because of the existence of state
external-review laws."
|
|
SD: 58-17C STANDARDS FOR MANAGED CARE PLANS
(Partial links)
58-17C-47
Prohibition against compensation influencing or based upon review
decisions.
58-17C-64
Registration of utilization review organizations--Required
information.
58-17C-67
Activities
of nonregistered utilization review organizations prohibited.
58-17C-103
Promulgation of rules--Consistency with federal requirements.
58-17C-34
Applicability of chapter 17C.
58-17C-35
Health
carrier responsibility for utilization review activities.
58-17C-36
Director
to hold health carrier responsible for utilization review
performance of contractor.
58-17C-37
Written
utilization review program required--Contents of program
document.
58-17C-38
Utilization review program to use documented clinical review
criteria--Criteria to be made available to authorized agencies
upon request.
58-17C-39
Program
to be administered by qualified licensed health care
professionals.
58-17C-40
Determinations to be issued in a timely manner--Process to
ensure consistency.
58-17C-40.1
Calculation of time period for determination for prospective and
retrospective reviews.
58-17C-41
Effectiveness and efficiency of program to be routinely
reviewed.
58-17C-42
Data
systems must support program activities and generate management
reports.
58-17C-43
Health
carrier oversight of delegated activities--Requirements.
58-17C-44
Utilization review to be coordinated with other medical
management activity of health carrier.
58-17C-45
Health
carrier to provide free access to review staff.
58-17C-46
Only
information necessary for review or determination to be
collected.
58-17C-47
Prohibition against compensation influencing or based upon
review decisions.
58-17C-48
Written
procedures required for making determinations--Notification.
58-17C-49
Prospective review determinations--Timing--Notification of
requirements-- Extension of time.
58-17C-50
Concurrent review determinations--Timing--Notification
requirements.
58-17C-51
Retrospective review determinations--Timing--Notification
requirements.
58-17C-52
Notification of adverse determination--Contents.
58-17C-53
Repealed.
58-17C-54
Information required to be provided to covered persons and
prospective covered persons.
58-17C-55
Certain
plans exempt from requirements of §§ 58-17C-34 to 58-17C-57,
inclusive.
58-17C-56
If
private accrediting body meets requirements, health carrier may
be deemed to have met them.
58-17C-57
Director
authorized to promulgate rules--Scope of rules.
58-17C-58
Establishment of grievance system by managed care plan or
utilization review organization.
58-17C-59
Record
of grievances--Report.
58-17C-60
Maintenance of grievance records--Accessibility.
58-17C-61, 58-17C-62.
Repealed.
58-17C-63
Promulgation of rules for grievance system.
58-17C-64
Registration of utilization review organizations--Required
information.
58-17C-65
Filing
changes in registration information.
58-17C-66
Requests
of information from utilization review organizations.
58-17C-67
Activities of nonregistered utilization review organizations
prohibited.
58-17C-68
Registration fee for utilization review organizations.
58-17C-69
Application of §§ 58-17C-58 to 58-17C-68, inclusive.
58-17C-70
"Urgent
care request" defined.
58-17C-71
Urgent
care requests--Written procedures for receipt and determination
of requests required.
58-17C-72
Urgent
care requests--Timely notification of determination.
58-17C-73
Insufficient information for determination--Notice and statement
of necessary information required.
58-17C-74
Insufficient information for determination of prospective urgent
care requests.
58-17C-75
Time
within which to submit necessary information.
58-17C-76
Urgent
care requests--Notice of determination--Failure to submit
necessary information grounds for denial of
certification--Notice of adverse determinations.
58-17C-77
Concurrent review urgent care requests--Requests for extended
care--Time to make determination and provide notice.
58-17C-78
Calculation of time periods for determinations.
58-17C-79
Notification of adverse determinations--Requirements.
58-17C-80
Register
of grievances required--Information to be compiled--Maintenance.
58-17C-81
Report
to director required--Contents of report.
58-17C-82
Grievance procedures--Filing with director required--Certificate
of compliance--Contact information required.
58-17C-83
Review
of adverse determinations--Time for filing--Designation and
notice of reviewers--Scope of review.
58-17C-84
Review
of adverse determinations--Rights of covered person or
authorized representative--Access to documentation.
58-17C-85
Review
of adverse determinations--Time for issuing decisions and
providing notice--Calculation of time periods.
58-17C-86
Issuance
of decision--Required contents.
58-17C-87
Health
carrier to establish review procedures for grievances not
involving adverse determinations.
58-17C-88
Standard
review--Covered persons or authorized representatives entitled
to submit written material only.
58-17C-89
Designation of person(s) to conduct standard review--Notice to
covered person or authorized representative.
58-17C-90
Standard
review--Time within which to notify covered person of decision--
Extension of time.
58-17C-91
Standard
review--Required contents of written decision.
58-17C-92
Additional voluntary review--Right of covered person to
appear--Required notice--Not applicable to health indemnity
plans.
58-17C-93
Additional voluntary review--Required notice--Rights of covered
person(s) or authorized representatives.
58-17C-94
Appointment of panel for voluntary review of first level review
decision--Scope of review--Composition of panel.
58-17C-95
Standard
review--Appointment of voluntary review panel--Composition of
panel.
58-17C-96
Procedures for appearance before voluntary review panel--Legal
representation--Time for issuance of decision.
58-17C-97
Notice
and issuance of decision when covered person does not request
appearance--Time for issuance of decision.
58-17C-98
Decision
by voluntary review panel--Required contents.
58-17C-99
Expedited review for adverse determinations involving urgent
care requests-- Appointment of peers for review.
58-17C-100
Expedited review not initial determination for
benefits--Transmission of necessary information.
58-17C-101
Expedited review decision not initial determination for
benefits--Time of notification--Continuation of service
involving concurrent review urgent care requests.
58-17C-102
Expedited review decision--Notification--Required contents.
58-17C-102.1
Applicability of §§ 58-17C-40 to 58-17C-102, inclusive.
58-17C-103
Promulgation of rules--Consistency with federal requirements.
36 PROFESSIONS AND OCCUPATIONS
(Partial links)
36-4B-34.1
Peer
review committee--Activities--Liability of members
36-4B-34.4
Peer
review activity defined
36-4-42 Peer
review committee defined
36-4-43 Peer review activities defined.
36-4B-34.2
Data
of peer review committee--Disclosure--Discovery--Admissibility--
Testimony
36-4-26.1
Proceedings of peer review
committees confidential and privileged--Availability to physician
subject of proceedings.
36-20B-53
Continuing professional
education or peer review as condition for reissuance of
certificate, license or permit.
36-5-16
Grounds
for refusal or revocation of license--Procedure.
36-5-16.1
Suspension, reprimand, or probation in lieu of
revocation--Hearing.
36-5-17
Appeal
from Board of Examiners.
36-5-18
Chiropractors Association reconstituted--Purpose--Annual
certificate of registration-- Report--Certification of dues
paid--Bylaws.
36-5-19
Peer
review committee--Immunity from liability--Conditions--Official
immunity unaffected--Fee.
36-5-20
Disciplinary committee--Immunity from
liability--Conditions--Official immunity unaffected.
36-5-21
Ethics
committee--Immunity from liability--Conditions--Official immunity
unaffected--Promulgation of rules.
20:06:33
Utilization review organizations and managed care entities.
20:06:34
Grievance procedures.
|
|
|
"[¶16.] Nevertheless, Linke argues that
the public policy behind the official proceedings privilege
requires its application in this context. The justifications
advanced for the position mirror those used for
quasi-judicial peer review of those placed in a position of
public trust. We agree that public policy justifies an
absolute privilege in the context of official quasi-judicial
proceedings as well as
statutorily authorized professional
peer review, however,
we decline to extend that privilege to
all employment relationships. Although we recognize the
position of trust held by a registered nurse, an
absolute
privilege under
20-11-5(2)
is not available outside an
official proceeding authorized by law. Therefore, the trial
court’s grant of summary judgment on this issue is
reversed." |
South Dakota Supreme Court
Martinmaas v. Engelmann, 2000 SD 85 6/28/2000
Opinion Filed On Wednesday, June 28, 2000
|
"[¶50] Applying these rules of statutory construction to this
case, Engelmann's claim, that the introduction of the
hearing transcript violated the confidentiality statutes,
has merit. A review of
SDCL 36-4-31.5 in the overall context
of
SDCL ch 36-4 reveals that the goal of the legislature was
to protect all confidential information that surfaces during
this type of proceeding - not only the physician's
information, but patients' information as well.
SDCL
36-4-26.1 is especially enlightening. It states in pertinent
part:
The proceedings, records, reports, statements, minutes,
or any other data whatsoever, of any committee described
in
§ 36-4-42, relating to the quality, type, or
necessity of care rendered by a member of a
hospital medical staff or by hospital personnel, or
acquired in the evaluation of the competency, character,
experience or performance of a physician, dentist or
allied health professional seeking admission or
reappointment to the medical staff of a hospital, are
not subject to
discovery or disclosure under chapter 15-6 or any other
provision of law, and are not admissible as evidence in
any action of any kind in any court or arbitration
forum, except as hereinafter provided.
[¶51] This provision indicates that anything
related to the "quality, type or necessity of care rendered"
or to the "competency, character, experience or performance"
of a physician is to remain
confidential. When
SDCL
36-4-31.5 is considered in pari materia to the rest of
SDCL
ch 36-4, it becomes
clear that the legislature intended for
a re-application hearing to remain confidential. The
confidential nature of the transcript was even acknowledged
by the trial court in its decision to release the
transcript." |
|
|
|
Why ERISA
Seminars for Health-care Providers?
|
Brief Summary Of
the
New Regulation
for Physicians and
ERISA Plans/TPAs |
|
Effective Date: January 01, 2003 |
|
For
Physicians and Health-care Providers |
For
Insurance Companies
ERISA Plans/TPAs |
|
ERISA's
Prompt Pay Law, better than State Prompt Pay Laws
[29 CFR § 2560.503-1
(f)(i),
Page 70267-9] |
ERISA's
Prompt Pay Law, better than State Prompt Pay Laws
[29 CFR § 2560.503-1 (f)(i), Page 70267-9] |
|
|
|
|
New Assignment of Benefit Form Required for
Appeals and Claim Dispute
(DOL
FAQ, B2-B3) |
No New Legal Assignment of Benefit Form, No
Obligations to Physicians and Health-care Service Providers
(DOL
FAQ B2),
otherwise Obligations to Disclose to Both Patients and Providers
(DOL FAQ B-3) |
|
|
|
|
No written appeal, no rights, except for claims
involved with urgent care.
[Page 70255 & 70271] |
In claims involved with urgent care,
physicians/health-care providers are to be considered by default as
authorized representatives.
[Page 70255 & 70271] |
|
|
|
|
The regulation clarifies for the first time since 1977 and
prohibits anti-assignment provisions in ERISA plans & (footnote 36).
[page 70255 ]
[29 CFR § 2560.503-1 (b) (4) Page 70266] |
Assignments by patients must be absolutely
clear as to what extent and capacity, verifications are permitted &
(footnote 36).
(DOL FAQ B-3)
[page 70255 & 70266]
[29 CFR § 2560.503-1 (b) (4), Page 70266] |
|
|
|
|
Must complete required two levels of appeals,
with legal assignment of benefits and specific written request for
disclosure of specific plan documents.
[Page 70253] |
No legal assignment of benefits, no response
required; no specific written request, no disclosure obligated,
however failure to establish and comply with claim procedures,
administrative remedies are considered to be exhausted. Lawsuit may
follow.
[Page 70271] |
|
|
|
|
New protections for pre-service claims and
urgent care claims against improper pre-authorization,
pre-certification and utilization review as well as urgent cares.
[Page 70248 & 70271] |
Understanding of differences in pre-service,
urgent care and post-service claims will save big money in fiduciary
breach liability claims and
POSSIBLE
medical malpractice claims. [Page
70248 & 70271] |
|
|
|
|
New definitions of relevant documents and
disclosure obligations, no more medical necessity secrets, UCR fee
schedule confidential
[Page 70252]
[29 CFR § 2560.503-1 (h)(2)(iii) (m) (4), Page 70268, 70271]
[DOL FAQ B-5] |
No legal assignment of benefits, no obligation
to disclose to an assignee, assignment verification by the plan is
allowed and protected.
Update SPD and any guidelines, only use disclosable and
qualified medical claim reviewers.
[Page 70252]
[29 CFR § 2560.503-1 (h)(2)(iii) (m) (4), Page 70268, 70271]
[DOL FAQ B-5] |
|
|
|
|
A Full and Fair Review with new definitions and
protection requires de novo reviews on two appeals by at least four
different people, two different fiduciaries with ERISA plan, and
two different Health-care professionals independent to the ERISA
plan.
[29 CFR § 2560.503-1 (h) (3)(ii)(iii)(iv)(v), Page 70268-9, (m) (8), Page 70271]
[Page 70252-70253] |
Update
SPDs with New Standards and compliance, specify and designate
only qualified fiduciaries for appeals, establish new complaint
appeal procedures, use only disclosable and licensed as well as
certified health-care professionals for medical reviews,
pre-certification and prior authorizations in every case.
[29 CFR § 2560.503-1 (h) (3)(ii)(iii)(iv)(v), Page 70268-9, (m) (8), Page 70271]
[Page 70252-70253] |
|
|
|
|
New clarifications on state law preemptions and
"independent" medical reviews. No preemption for state laws unless
prevention of the application of the new regulation
[Page 70254] |
Comply with both
the regulation and state laws in claims involving mixed
treatment and eligibility determinations and pure medical treatment
decision-makings.
[Page 70254] |
|
|
|
|
New clarifications with new definitions claim
denial/an adverse benefit determination (payment<100% claimed)
or Overpayment, and new protections.
(DOL FAQ C-12) |
Overpayment vs. an adverse benefit
determination, recoupment vs. appeal procedures.
(DOL FAQ C-12) |
|
|
|
|
SPDs must
describe...... |
No SPDs, No
decision making |
|
|
|
|
Insurance company's decision-making power and
disclosure obligations must be described in SPD
[29 CFR 2520.102-3 (q), Page 70242] |
Fully-insured plans with a health insurance
issuer being wholly or partially responsible for administering the
plan (e.g. payment of claims) must describe insurer's role in SPD.
[29 CFR 2520.102-3 (q), Page 70242] |
|
|
|
|
Claim fiduciary, whoever makes denial
appeal decisions, has duties to disclose
SPD and relevant document
[29 CFR § 2560.503-1 (h)(2)(iii), (3)(iii) Page 70268-9, (m) (8), Page 70271] or may face up to $110 a day penalty under "Prudent Actions by Plan
Fiduciaries" and "Enforce Your Rights."
[29 CFR § 2520.102-3, Page 70243] |
Claim fiduciaries or plan fiduciaries
have new duties to disclose, without charge,
SPD and relevant
document
[29 CFR § 2560.503-1 (h)(2)(iii), (3)(iii) Page 70268-9, (m) (8), Page 70271] when claim for
benefits is denied or delayed, or may face up to $110 a day penalty
under "Prudent Actions by Plan Fiduciaries" and "Enforce Your
Rights."
[29 CFR § 2520.102-3, Page 70243] |
|
Failure to timely
make benefit determination and review decisions by the plan
administrator will constitute "deemed denied" review/appeal and
"deemed exhaustion of administrative remedy" under
§ 2560.503-1(l), ("a decision on the
merits of the claim" = de novo judicial review, instead of
deferential judicial review) that will forfeit or preclude
the plan from "deferential review standard" on judicial review in
federal court,
the most important part of "ERISA Shield" on ERISA land.
Gilbertson v Allied Signal Inc |
DOL interprets
§
2560.503-1(l) through CFR accompanying supplementary information on
page 70255: “The Department’s intentions in including this
provision in the proposal were to clarify that the procedural
minimums of the regulation are essential to procedural fairness and
that
a
decision made in the absence of the mandated procedural protections
should not be entitled to any judicial
deference.” |
|
More.... |
More.... |
|
|
|
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.
|
|
|
$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.
|
|
|
|
|
|
|
|
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. |
|
|
|
|
|
