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"The terms of a participant's particular benefit plan document [Group Service Agreement (GSA), Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Positions are based. If these Coverage Positions are inconsistent with the terms of the member's specific benefit plan, then the terms of the member's specific benefit plan always control."

 

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Your patient's medical benefits are governed and determined by a benefit document, either a Certificate of Coverage or a Summary Plan Description. You should not rely on the information contained in this Web site section to determine your patient's medical benefits.
 

  1. Federal and state mandates and the patient’s benefit document take precedence over these policies.

  2. The patient’s benefit document lists the specific services that have coverage limits or exclusions.


Our Medical Policy does not address every situation and individuals should always consult their physician before making any decisions on medical care."

 

 

 

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New Federal Health Claims & Appeals Laws & Regulations

for 193 Million Americans

Effective 09-23-2010

©2010, Jin Zhou, ERISAclaim.com

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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

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UNITED STATES

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(Links to DOL) ©2010, Jin Zhou, ERISAclaim.com

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Health Claims Related Information

Webinars, Seminars & Certification Classes for New Federal Health Claim Appeals Regulations

 

ERISAclaim.com - Free Webinars - New Federal Claims & Appeals Regulations, Effective Sept. 23, 2010, for 193 Million Americans

 

ERISAclaim.com: Seminars - 2010 Two-day Basic ERISA Appeal Seminars - Denials and Overpayment Appeals

 

ERISAclaim.com - 2010 PPACA & ERISA Claim Specialist Certification Programs in Chicago, Illinois

 

ERISAclaim.com:  Create An Appeal Department for Your Hospital or Practice (In-house, onsite ERISA Claim Specialist Certification Programs)

 

Helping make sense of health care reform (San Francisco Chronicle, August 10, 2010)

"Q: Are most plans going to stay grandfathered?

 

(Borzi ) A: I had the strong sense that most companies, at least initially, would want to stay grandfathered to see what the whole panoply of regulations would look like, and then decide. What I hear is that a lot of the large companies don't want to do the analysis to decide (whether it makes sense to stay grandfathered). They are just going to assume they are not grandfathered."

 

"Borzi is head of the U.S. Department of Labor's Employee Benefits Security Administration,"

Survey Notes Most Health Plans to Lose Grandfathered Status | workforce.com - August 11, 2010  

"Seventy-two percent of employers expect their health care plans to lose their grandfathered status because of design changes. Changing premium subsidy levels, changing insurers and consolidating plans are among other actions employers expect to result in their plans losing grandfathered status."

 

New Webinars, Seminars & Certification Classes Announced for New Federal Health Claim Appeals Regulations on July 22, 2010 from HHS, DOL & Treasury    08/05/2010  Hanover Park, IL

New Webinars, Seminars & Certification Classes Were Announced by ERISAclaim.com for New Federal Appeals Regulations Issued on July 22, 2010 by HHS, DOL & Treasury for 193 million Americans. Effective 09/23/2010, New Federal Reimbursement Laws Mandate ERISA Internal Appeals and NAIC External Appeals For All Group and Individual plans With Six New & Most Powerful Consumer Protections

2010 Claim Denial & Overpayment Dispute

 

Two-day Basic ERISA Appeal Seminars

 

Chicago, Illinois

 

New Federal Appeals Regulations Go Into Effect on

Sept. 23, 2010

 

Class Dates: Sept. 22--23, 2010

Class Dates: Oct. 27-28, 2010

Class Dates: Dec. 16-17, 2010

 

  8 hours (8 am -12 pm & 1 pm - 5 pm)

 

$700/first person; $350/additional

Call: 630-808-7237

For more info: http://www.erisaclaim.com/seminars.htm

 

(E-mail Your Questions or Wish List for Future Seminar Dates & Locations to ERISAclaim@aol.com)

 

How to Sign up?

 

               Our new 2009 ERISA Seminars can be enrolled by

 

1. Calling 630-808-7237

 

2. Download, fax a completed Registration Form to 630-736-1439 (coming soon)

 

3. Online Secured registration.

 

Maximizing Healthcare Claim Reimbursement

Problem Oriented Appeals under ERISA

New Federal Appeals Regulations Promulgated On July 22, 2010, Effective Sept. 23, 2010 For 193 Million Americans

“The new appeals regulations were issued by the Departments of Health and Human Services (HHS), Labor, and the Treasury. Consumers in new health plans in every State will have the right to appeal decisions, including claims denials and rescissions, made by their health plans."

 

The new appeals regulations go into effect on Sept. 23, 2010, for about 193 million Americans, according to DOL.

 

The new appeals regulations are six times better and stronger than previous patchwork for consumers with immediate and powerful protections and remedies if a health plan or insurer fails to strictly adhere to ALL requirements of the new Regulations.

 

The new appeals regulations mandate ERISA internal appeals and NAIC external appeals for all group health plans and individual policies.

 

“On average, about 40 percent of denials are reversed on external appeal” as stated in the preamble of the new Federal Appeals Regulations.

 

Seminar Goals:

 

  1. To Understand Basic Concepts and Protections of New Federal Appeals Regulations Issued On July 22, 2010 by HHS, DOL & Treasury
  2. To Understand Basic Definitions Of ERISA Claim  Regulation And Appeal Practice;
  3. To Understand Relevant Provisions Of ERISA Claim Regulation, CFR ERISA §2560.503-1;
  4. To Understand DOL Guidelines Of ERISA Claim Regulation And Appeal, DOL ERISA FAQ;
  5. To Understand Relevant Provisions Of ERISA Summary Plan Description (SPD) Regulation;
  6. To Understand Basic Application Of The ERISA Claim And SPD Regulations In Healthcare Claim Appeals;
  7. To Understand Most Significant U.S. Supreme Court And Federal Court Rulings, Case Laws, For ERISA Claim Litigation And Appeals;
  8. To Understand How To Quickly Identify ERISA Plans;
  9. To Understand How To Identify Plan Administrator From the ERISA Plans;
  10. To Understand How To Read Insurance Denial Notification/EOB From ERISA Standpoint;
  11. To Understand Relevant State Laws And Managed Care Regulations In Support Of ERISA Appeals;
  12. To Understand General Principle And Practical Applications Of Denial Fact Findings, Laws And Regulations And Appeal Strategies;
  13. To Understand How To Appeal Commonly Seen Denials Under ERISA In Healthcare Claims, Policy Exclusion And Limitation, Medical Necessity, UCR, Precertification/Prior Authorization, Pre-Existing Condition Exclusion, Subrogation, Coordination Of Benefits/EOB, Lack Of Documentation, Lack Of Authorization To Appeal, And More……;
  14. To Understand How To Appeal Claim Denials And Delays With Very Specific Allegations of ERISA Violations From Payers, Beyond and Above Coding, Billing and PPO/HMO Contracting Arguments;
  15. To Understand How To Appeal Overpayment Recoupment Demand And Withholding/Embezzlement;
  16. To Understand Basic Principles And Procedures For Healthcare Provider In Fraud And Abuse Prevention;
  17. To Understand Federal Law And Regulations On Indigency Policy, Discount Programs In Compliance With Federal Laws, A New Risk That Unkown to Providers In Overpayment And Fraud Disputes;
  18. To Understand How To Communicate With Attorneys Retained By ERISA Plans And Plan Administrators Of Self-Insured Health Plans For Speedy Settlement;
  19. To Understand How To Quickly Identify And Correctly Use The Sample Letters From ERISA Appeal CD Book From Jin Zhou Of ERISAclaim.com;
  20. Based On The Individual Practice, To Identify and  Make Recommendations And Changes For Medical Practice Forms, Such As Legal Assignment Of Benefits, Medical Necessity, Financial Discount/Corporate Indigency Policy;
  21. Will Answer Any Specific Questions From The Real Claim Denials On Ongoing Basis During The Seminar.

Note: Some group discounts are per seminar based.

Fees
  1. $700 for the first person, $350 for additional staff  from the same office/Co.

  2. 50% discount off all CD Books at the seminar

 

Lunch will be on your own

Discounts

CD-Books: 50% Discount at the seminar

Location

Chicago (Hotel To Be Determined)

Dates

See Above, 8hrs (8 am -12 pm & 1 pm - 5 pm)

 

 

 

 

"Maximizing Healthcare Claim Reimbursement

 - Problem Oriented Appeals under ERISA"

 

Did you know that ERISA completely controls or regulates all of your claim denials and delays from employer-sponsored plans, as long as your dispute is reimbursement:  "denial of benefits", and if you were very and really frustrated?  (Unanimous US Supreme Court Decision on June 21, 2004) Did you also know that most employer-sponsored plans in USA, not only self-funded/insured but also fully-insured (through purchase of insurance), are ERISA plans, and most of your reimbursement claims for patients under age of 65 are ERISA claims?

 

Aetna Health Inc. v. Davila

06/21/04

Opinion of the US Supreme 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),......"

 

  1. What is the law protecting patients against managed care problems for claims with employer sponsored health plans?

  2. Why did a US Supreme Court unanimously rule on June 21, 2004 that ERISA governs all of your claim denials or money problems from an employer sponsored health plan and ERISA supersedes all of your state laws for your "denial of benefits" (money problems) in your managed care troubles?

  3. Federal ERISA claim regulation protects patients from all of your managed care troubles, such as claim delays, coverage denials, "over-payment" money back hassles, choice of network and providers, prior-authorizations, policy "limit", silent PPO's,  "Mad HMO's",  down-coding and bundling to pay only a fraction of your claims, medical necessity problems, and all of your managed care problems;

  4. How to best use federal ERISA and state laws in utilization review (UR/medical necessity review) and external reviews to get your claim paid timely and reasonably?

  5. ERISA claims compliance and anti-fraud and abuse prevention.

 

ERISA, the federal law, requires every ERISA plan to disclose every relevant information for each denied claim, and provides most  powerful full and fair reviews to protect patients and providers, but ERISA was never fully understood and taught to health-care providers and the billing industry nationwide.

 

New Denial Crisis Demanding for New Solutions

for Your Reimbursement Problems

 

               In 2009, healthcare providers are facing unprecedented reimbursement crisis for healthcare claim denials, delays and "overpayment" recoupment as well as managed care PPO audits.

 

               Several years ago, most health care providers were seeing class actions against insurance companies and managed care entities by 950,000 physicians across USA after terribly failed political actions of "Patient's Bill of Rights" campaign for eight years, and desperately hoping to see some positive changes.  In last several year those class actions were either settled or dismissed by federal court.

 

               Do you see any major positive changes for your reimbursement?

 

               No!

 

               Now in 2009, the game is totally different.  More and more healthcare providers are the target of healthcare fraud lawsuits and investigations, PPO fraud and abuse audits, and more detrimentally harmful to financial bottom line for many healthcare providers and facilities. We have been experiencing more and more Volcano type of PPO audits and tornado type of overpayment recoupment crisis from payers withholding subsequent claim payments for millions of dollars, while no federal or state agency seemed to have jurisdictions for healthcare provider’s Katrina crying for justice, and while state government declined to intervene because of ERISA preemption and federal government refused to investigate because of alleged provider network contract agreement dispute, but healthcare providers on behalf of your patients received no payments or little payments for already approved claims as a result of "overpayment" recoupment by the payers.

 

Most Comprehensive Research and Analysis from US Supreme Court Rulings

 

               US supreme court unanimously ruled on June 21, 2004 that ERISA, a federal law, controls and governs your problems in managed care crisis if you want any money from the employer sponsored health plans.

 

Most Comprehensive, Advanced And Practical Appeal Letters For “Overpayment Recoupment” Due To PPO Audits And Medical Necessity As Well As Poor Documentation For Both Self-Funded ERISA Plan And Fully-Insured ERISA Plan

 

               Our new 2007 major updates provide you with most powerful protections and advanced appeal letters based on all of US Supreme Court recent rulings on managed care reimbursement, ERISA state law and PPO preemption, state law medical review preemption, and every type of practical arguments used by payers in withholding and recouping benefits payment from healthcare providers for those already approved benefits claims.

 

Latest Federal Court Ruling on Disallowing Health Plan Recovery or Recoupment against Healthcare Providers

 

               Two new federal court rulings on overpayment and state law prompted pay preemption relied upon most recent US Supreme Court rulings, in addition to our 2006 updates in this area.

 

Latest Federal Court Ruling on Definitive ERISA Preemption of State Prompt Pay Law.

 

               For years, federal and state regulators, legal and health care experts, health care providers and insurance companies are not certain if federal law ERISA preempts state Prompt Pay Laws, now federal court has ruled clearly that ERISA definitely preempts state prompt pay laws based on analysis of Supreme Court recent rulings.

 

97.96% Claims of United Healthcare Lawsuit in These Case Were ERISA Claims

 

               You will be also surprised to learn that in this provider lawsuit against United healthcare for wrongful denial of benefits claims

 

"Plaintiffs lawsuit centers around 295 claims for services rendered by Schoedinger to patients covered by United healthcare plans. 289 of these claims qualify as Employee Welfare Benefit Plans under ERISA, and 6 involve non-ERISA plans.5 268 of the ERISA claims surround self-funded or self-insured health plans, in which the employers are financially liable for any benefits due and United serves only as the plan administrator and claims processor. 21 of the ERISA claims and all of the non-ERISA claims involve health plans that are fully insured by United. For these 27 claims, United is financially responsible for the benefits due to plan participants and serves as the plan administrator and claims processor."

 

No PPO Participation, No Checks to Non-PPO Providers, but ERISA Laws Protect You

 

               Because certain major payers are no longer sending reimbursement checks to healthcare providers who were not participating in the network, we have thoroughly researched federal law, ERISA, and developed a most powerful but straightforward action plan package based on specific federal ERISA regulation and requirements for healthcare providers to receive reimbursement checks directly from the insurance payers.

 

New Federal Government Guidelines on Filing Benefits Claims and Appeals

 

               Our 2007 major updates also include latest federal government, DOL, guidance on filing healthcare claims and appeals

 

New Federal Government Guidelines on Pre-Existing Condition Denials and Protections

 

               Our 2007 major updates also include latest federal government, DOL, guidance on filing healthcare claims, appeals for pre-existing condition protections.

 

               Our U.S. employment market in modern society, divorce, relocation and adoption as well as newborn babies have caused countless mysterious claim denials and delays due to mysterious “additional information requesting” by payers from patients and health care providers, but healthcare providers can never find out what exactly addition information the payers are looking for.  These confidential information is not about privacy compliance but pre-existing condition investigation, also governed by HIPAA, money part of HIPAA regulation.

 

               HIPAA pre-existing condition regulation was never fully understood by healthcare providers, as HIPAA is part of ERISA regulation.

 

               If you want to get paid quickly and accurately for 90% of your non-Medicare claims from patients obtained health insurance from employment in private sectors, you must understand and follow published federal government guidelines.

 

How to Sign up?

 

               Our new 2009 ERISA Seminars can be enrolled by

  1. Calling 630-808-7237

  2. Download, fax a completed Registration Form (coming soon) to: 630-736-1439

  3. Online Secured registration.

 

 

About Dr. Jin Zhou

 

Dr. Jin Zhou is a national speaker, consultant, author and publisher of health-care ERISA claim denials & appeals, regulation education and compliance. He pioneered, authored and published the nation's first ERISA Health-care Claim Appeal System in a CD book, and the nation's first website (www.ERISAclaim.com) in ERISA healthcare claim denials, appeals, claim regulation education and compliance, “ERISAclaim.com”.

 

He has taught ERISA seminars across the country in past 5 years to health-care providers, hospitals, billing and coding professionals, and managed-care organizations.  Dr. Zhou’s articles and expert advice were quoted and appeared on numerous industry professional magazines, web sites and organizations.  Dr. Jin Zhou was an orthopedic surgeon with Air Force General Hospital in China prior coming to United States in 1988. He is a licensed chiropractic physician in Illinois since 1991. In addition to his ERISA compliance and educational practice, he maintains an active clinical practice in Chicago suburb in Illinois. Dr. Zhou has been actively participating in teaching and innovative clinical research in medical science (www.SleepApneaUSA.net).

 
 

 

 

NBC 10 Breaking News:

Overpayment - FBI - Class Action

"Biggest Fraud in US History"

NBC10 Video

Blue Cross sues doctor over payments 


NARRAGANSETT, R.I. -- Just two days after a Narragansett doctor leveled strong accusations against Blue Cross & Blue Shield of Rhode Island, he learned he was being sued. Blue Cross filed a $100,000 lawsuit against Dr. Jay Korsen for damages caused by his going public with his complaints. - turnto10.com - Jun 19, 2009

 

Doctor claims Blue Cross withheld payments 


http://www.turnto10.com/jar/news/local/article/doctor_says_bcbs/14643/
A local chiropractor says he was strong armed by Blue Cross & Blue Shield of Rhode Island. The Narrangansett doctor says Blue Cross withheld money from him and he charges them with intimidation. -  turnto10.com - Jun 17, 2009

 

Pomerantz Files Class Action Against Blue Cross Blue Shield Association

 

Sept. 10, 2009

"Pomerantz filed a class action lawsuit against the Blue Cross Blue Shield Association ("BCBSA") and 22 leading BCBS insurers across the country on behalf of a putative nationwide class of health care providers, as well as the Pennsylvania Chiropractic Association ("PCA"), the New York Chiropractic Council (the "Council"), and the Association of New Jersey Chiropractors ("ANJC"). The suit challenges the Defendants' abusive practices in using post-payment audits and reviews, and improper repayment demands, to pressure providers to repay substantial sums that have previously properly been paid as health insurance benefits for services provided to BCBS subscribers."

For a copy of the BCBSA Complaint, click here

 

 

read

 

Pomerantz Files Class Action Against Blue Cross Blue Shield Association ("BCBSA") and Related BCBSA Entities

Reuters, Thu Sep 10, 2009 6:11pm EDT

 

CHICAGO--(Business Wire)--

"Pomerantz Haudek Grossman & Gross LLP today announced that it and co-counsel Buttaci & Leardi, LLC filed a class action lawsuit against the Blue Cross Blue Shield Association ("BCBSA") and 22 leading BCBS insurers across the country on behalf of a putative nationwide class of health care providers, as well as the Pennsylvania Chiropractic Association ("PCA"), the New York Chiropractic Council (the "Council"), and the Association of New Jersey Chiropractors ("ANJC"). The suit challenges the Defendants` abusive practices in using post-payment audits and reviews, and improper repayment demands, to pressure providers to repay substantial sums that have previously properly been paid as health insurance benefits for services provided to BCBS subscribers.

 

......In making the appointment, the Court stressed the significant role Pomerantz had played in a $249 million settlement of its UCR class action against Health Net, stating that the Court had "similarly appointed Pomerantz to be Plaintiffs` spokesman to the Court in the Health Net litigation because the Court found D. Brian Hufford, Esq. to be the attorney most capable of presenting Plaintiffs` position in a clear and concise manner." In re Aetna UCR Litig., 2009 Dist. LEXIS 66853, *8 n.4 (D.N.J. July 31, 2009)."

For a copy of the BCBSA Complaint, click here

 

Pomerantz Files Class Action Against Aetna (News from Pomerantz)

 

For a Copy of the Official Complaint, click here

 

Pomerantz Files Class Action Suit Against Aetna On Behalf of Healthcare Providers to Challenge Abusive Post-Payment Audit Practices (GlobeNewsWire, press release)

"NEWARK, N.J., July 29, 2009 (GLOBE NEWSWIRE) -- Pomerantz Haudek Grossman & Gross LLP today announced that it and co-counsel Buttaci & Leardi, LLC, have filed a class action lawsuit against Aetna, Inc., and its various health insurance subsidiaries on behalf of a putative nationwide class of health care providers, the Association of New Jersey Chiropractors ("ANJC") and the New York Chiropractic Council ("NYCC"). The suit challenges Aetna's abusive practices in using post-payment audits, with false allegations of fraud, to pressure providers to repay substantial sums that have previously properly been paid for providing services to Aetna subscribers.

The action alleges that Aetna's post-payment audit process violates the Employee Retirement Income Security Act of 1974 ("ERISA"), in that its repayment demands are retroactive determinations that particular services are not covered under the terms of Aetna's health care plans, but without any of the appeal or other protections otherwise available under ERISA for both self-funded and fully insured health care plans offered through private employers. The complaint further alleges that both the post-payment audit process and the pre-payment claim review process employed by Aetna to strong-arm chiropractors into unfavorable settlements violate the Racketeer Influenced and Corrupt Organizations Act ("RICO"). In addition to challenging the process by which Aetna pursues and applies its audits, the complaint also challenges numerous clinical policy bulletins of Aetna, which are used to deny services retroactively without adequate basis or clinical support."

ERISAclaim.com - "Overpayment" Refund Request Response & Appeals

BCBSA News, June 30, 2009

Blue Cross And Blue Shield Companies' Anti-Fraud Efforts Recover $350 Million In 2008

"WASHINGTON – Blue Cross and Blue Shield companies' anti-fraud investigations resulted in overall savings and recoveries of nearly $350 million in 2008, an increase of 43 percent from 2007, according to data released today by the Blue Cross and Blue Shield Association (BCBSA) National Anti-fraud Department (NAFD).  From 2007 to 2008, the number of cases opened increased nearly 34 percent, and the closed cases increased about 43 percent."

AMNews: July 6, 2009. Tennessee Medical Assn. sues collections firm
Health Research Insights has contacted physicians in several states this year trying to collect alleged overpayments.

 

For A Copy of TMA v. HRI Lawsuit, click here
 

AMNews: May 18, 2009. State medical societies strategize against collector
Legal action is one option against Health Research Insights.
 

AMNews: May 11, 2009. Company stops tapping physicians for 'overpayments'
Doctors protested self-insured Georgia-Pacific's attempt to collect refunds of suspected claims upcoding.
 

AMNews: April 13, 2009. Self-insured companies going after doctors to recover 'overpaid' claims
There is no clear time limit on how far back ERISA-protected companies can go to recoup money. One company is turning that into a business.

 

Overpayment Demand Letter from HRI:

"Dear Health Care Professional,

 

......You must take action as outlined in items (1) or (2) above, in order to ensure compliance with the Employee Retirement Income Security Act of 1974 (ERISA). ERISA is the federal law that, among other things, governs health benefit plans in private industry. Investigation of potential ERISA violations is given to the United States Secretary of Labor pursuant to sections 504 and 506 as amended by the Comprehensive Crime Control Act of 1984 and enforced by the US Department of Labor.

 

In the event HRI is not contacted by you or your designee, a Complaint may be filed with the Employee Benefits Security Administration (EBSA). You may view additional information at (www.dol.gov/ebsa)."

Physicians Strike Back At Employers' Collection Firms ( BNET Healthcare Blog | BNET)

"In the most recent clash, the Tennessee Medical Association has sued Health Research Insights (HRI), a Franklin, TN-based firm that has sent collection letters to physicians in Georgia, Kentucky, Tennessee and Texas. Other defendants in the suit include the Metropolitan Government of Nashville and Davidson County, TN, and Nashville’s Board of Education, which runs a self-insured plan for school employees. Blue Cross and Blue Shield of Tennessee, the plan’s administrator, is also named in the suit, although the insurer disavows any relationship with the collection firm.

 

The suit, which alleges fraud, says that HRI keeps 40 percent of whatever it collects. The TMA wants a court to enjoin HRI from making any further efforts to collect from physicians. An earlier protest by the Georgia Medical Society against HRI’s work on behalf of Georgia Pacific led to a suspension of those activities."

Employment-Based Health Coverage and Health Reform: Selected Legal Considerations (PDF) (U.S. Congressional Research Service)

"It is estimated that nearly 170 million individuals have employer-based health coverage. As part of a comprehensive health care reform effort, there has been support (including from the Obama Administration) in enacting comprehensive health insurance reform that retains the employerbased system. This report presents selected legal considerations inherent in amending two of the primary federal laws governing employer-sponsored health care: the Employee Retirement Income Security Act (ERISA) and the Internal Revenue Code (IRC)."

ERISAclaim.com - "Overpayment" Refund Request Response & Appeals

 

 

 







Past  Seminars 2006 - 2008

(for Reference only)

 

2006 Reimbursement Seminars

Problem Oriented ERISA & Medicare Claims

&

New IL WC Laws

 

"Problem Oriented" =???

  1. Bring your actual denied claims with EOB's and failed appeals as well as your frustrations,

  2. We will show you the most applicable & powerful laws & regulations to guide your successful appeals!

 

 

 

 

Finally a Reimbursement Seminar with Information that is Really "KRYPTONITE"

Sponsored by The New York Chiropractic Council & Chirocode Institute

Thursday September 14th, 2006, 8am - 2pm

Crown Plaza Hotel, LaGuardia Airport
104-04 Ditmars Airport,
East Elmhurst, NY 11369

Click Here to download Flyer: Erisa Doc

Chirocode Sponsored Monthly National Seminars by Dr. Jin Zhou of ERISAclaim.com

 

Dr. Jin Zhou will speak at "11th Annual Medical Billing National Conference" on May 10th, 2006 sponsored by Synergy Medical Information Systems and Electronic Network Systems on:

"Maximizing Healthcare Claim Reimbursement - Problem Oriented Appeals under ERISA"

 

"Mastering the 2006 Medicare Appeal Process"

 

For More Information

CALL:  1-630-736-2974

E-mail Your Questions to ERISAclaim@aol.com

Note: Some group discounts are per seminar based.

Fees ERISA: $350 Medicare: $350 IL WC: 350
Discounts $50 off each if paid 30 days in advance, and another $50 off total if taking more than one seminar.

 

$100 off each seminar if taken any of our seminar of the same topic before (not including different topics).

 

CD-Books: 20% off on all CD-Books at Seminars.

Location Oakbrook, IL Oakbrook, IL Oakbrook, IL
Dates

Topics: ERISA, Medicare & IL WC

 

 

Topics I

 

9AM - 5PM

FOR ALL DATES

 

March 30, 2006

 

April 20, 2006

 

June 08, 2006

 

July 20, 2006

 

Aug. 17, 2006

 

Sept. 21, 2006

 

Oct. 19, 2006

 

Nov. 16, 2006

 

Dec. 21, 2006

 

 

 

 

 

 

 

 

"Maximizing Healthcare Claim Reimbursement

 - Problem Oriented Appeals under ERISA"

 

Did you know that ERISA completely controls or regulates all of your claim denials and delays from employer-sponsored plans, as long as your dispute is reimbursement:  "denial of benefits", and if you were very and really frustrated?  (Unanimous US Supreme Court Decision on June 21, 2004) Did you also know that most employer-sponsored plans in USA, not only self-funded/insured but also fully-insured (through purchase of insurance), are ERISA plans, and most of your reimbursement claims for patients under age of 65 are ERISA claims?

 

Aetna Health Inc. v. Davila

06/21/04

Opinion of the US Supreme 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),......"

 

  1. What is the law protecting patients against managed care problems for claims with employer sponsored health plans?

  2. Why did a US Supreme Court unanimously rule on June 21, 2004 that ERISA governs all of your claim denials or money problems from an employer sponsored health plan and ERISA supersedes all of your state laws for your "denial of benefits" (money problems) in your managed care troubles?

  3. Federal ERISA claim regulation protects patients from all of your managed care troubles, such as claim delays, coverage denials, "over-payment" money back hassles, choice of network and providers, prior-authorizations, policy "limit", silent PPO's,  "Mad HMO's",  down-coding and bundling to pay only a fraction of your claims, medical necessity problems, and all of your managed care problems;

  4. How to best use federal ERISA and state laws in utilization review (UR/medical necessity review) and external reviews to get your claim paid timely and reasonably?

  5. ERISA claims compliance and anti-fraud and abuse prevention.

 

ERISA, the federal law, requires every ERISA plan to disclose every relevant information for each denied claim, and provides most  powerful full and fair reviews to protect patients and providers, but ERISA was never fully understood and taught to health-care providers and the billing industry nationwide.

 

Dr. Jin Zhou, Founder & President of ERISAclaim.Com, the pioneer of ERISA appeal system for providers will show you what US Supreme Court ruled on nation's managed-care disputes and how ERISA can really maximize your reimbursement practice through compliance.

 

Topics II

 

 

9AM - 5PM

FOR ALL DATES

 

March 31, 2006

 

April 21, 2006

 

June 09, 2006

 

July 21, 2006

 

Aug. 18, 2006

 

Sept. 22, 2006

 

Oct. 20, 2006

 

Nov. 17, 2006

 

Dec. 22, 2006

 

Medicare New Appeal Rules for All Claims

Effective 01/01/2006

 

"Mastering the 2006 Medicare Appeal Process"

 

Starting on January 1, 2006, the NEW Medicare Appeal Process went into effect for all Medicare claims in the USA.  According to CMS, this is the most significant overhaul in Medicare history for claim denials and appeals.  You may have noticed these changes from your local Medicare carrier or in frustration after your Medicare claims have been denied recently.

 

If you want to get paid by Medicare, you have no choice but to comply with the NEW Medicare Appeal Process.  Since this is the most significant Medicare claim appeal overhaul in history and new to everyone, we must get very serious at learning and mastering this new Medicare Appeal (reimbursement) Process and practice for your survival and compliance.  Learn how to master the new Medicare Appeal Process during this very important session.

 

 

  1. New Medicare appeal laws for all claims, effective 01-01-2006;

  2. Most significant overhaul in Medicare history;

  3. Comparison between old rules and new rules;

  4. Is new law better than old law?

  5. Who is the new Medicare contractor for your level two appeals?

  6. How to file appeals for fast payment under new Medicare Appeal rules?

  7. and more at http://www.erisaclaim.com/CMS_New_Appeal_Rules.htm

 

One of the main goals for ERISAclaim.com is to assist Medicare’s 1.2 million physicians and other providers with the information they need from CMS and our unique but practical guidance with compliant strategy to correctly  appeal Medicare denied or delayed claims in accordance with Medicare rules and regulations, as intended by Congress, to receive reimbursements more quickly, and spend less time dealing with paperwork ultimately.

 

Topics III

 

9AM - 5PM

FOR ALL DATES

 

Feb. 27, 2006

 

March 20, 2006

 

April 24, 2006

 

June 19, 2006

 

July 03, 2006

 

Aug. 21, 2006

 

Sept. 25, 2006

 

Oct. 30, 2006

 

Nov. 20, 2006

 

Dec. 11, 2006

 

 

New Illinois Workers' Compensation Laws

for Healthcare Providers

 

 

  1. New workers’ compensation law in Illinois
  2. Illinois Supreme Court opinions on causation
  3. Medical Necessity and Utilization Review
  4. Utilization Review v Case Management
  5. Utilization Review v "Work-related injuries"-Causation
  6. Utilization Review v. "disability" impairment rating
  7. Medical Necessity Appeal Strategies
  8. New Appeal Forms and Letters to Comply with HB 2137 for Prompt Payment under New Illinois Workers' Compensation Laws
  9. No Patient Balance Billing, No UCR's, URAC Appeals, and Reminders as Well as When to Bill Health Plan for WC Claims
  10. How to find WC Carrier and verify WC benefits under new Illinois WC Laws;
  11. Penalties, Late pay Interest Rate and more....

 

 

About Dr. Jin Zhou

 

Dr. Jin Zhou is a national speaker, consultant, author and publisher of health-care ERISA claim denials & appeals, regulation education and compliance. He pioneered, authored and published the nation's first ERISA Health-care Claim Appeal System in a CD book, and the nation's first website (www.ERISAclaim.com) in ERISA healthcare claim denials, appeals, claim regulation education and compliance, “ERISAclaim.com”.

 

He has taught ERISA seminars across the country in past 5 years to health-care providers, hospitals, billing and coding professionals, and managed-care organizations.  Dr. Zhou’s articles and expert advice were quoted and appeared on numerous industry professional magazines, web sites and organizations.  Dr. Jin Zhou was an orthopedic surgeon with Air Force General Hospital in China prior coming to United States in 1988. He is a licensed chiropractic physician in Illinois since 1991. In addition to his ERISA compliance and educational practice, he maintains an active clinical practice in Chicago suburb in Illinois. Dr. Zhou has been actively participating in teaching and innovative clinical research in medical science (www.SleepApneaUSA.net).

 

 

For More Information

CALL:  1-630-736-2974

E-mail Your Questions to ERISAclaim@aol.com

 

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

 

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

 

 

 

Driving Directions 

 

 

For Fax Registration
Click here to Download PDF/Fax verion of Registration Form

2006 Reimbursement
Seminars

Problem Oriented ERISA & Medicare Claims

&

New IL Workers’ Compensation Laws


www.ERISAclaim.com


Focusing on Problem Oriented Denials & Delays

Powered by

US Supreme Court Opinions & Federal Regulations

New Medicare Appeal Rules

 

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REGISTRATION FORM & PAYMENT

 

Seminar Fee

including lunch only, dinner & Hotel are not included

30 Days in Advance

$300 per seminar

Regular Fee

$350 per seminar

Previous Attendee

$250 per seminar

 

 

 

 

Seminar Topic: _______________________Dates:__________

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(Note: All credit card receipt are processed under the Name of

 

“Century Chiropractic and Acupuncture Clinic”

 

 

SEMINAR HOURS & LOCATION

9 a.m. to 5 p.m. for all seminars dates

2425 W. 22nd St, 2nd Fl Conference Room

Oak Brook,  IL

HOW TO REGISTER

On-line
Registration at

    http://www.ERISAclaim.com/seminars.htm

By Fax

    Fax the Form Completed to 630-736-1439

By Mail

     Mail This Form Completed to:

Jin Zhou

ERISAclaim.com

1260 Bamberg Court

Hanover Park, IL 60133

 

 

SEMINAR INFORMATION

Seminar registration will be at 8:30 A.M.

 

The Seminar will begin at 9 a.m. and wrap up at 5 p.m..  Lunch will be provided 12:30 p.m. to 1:30 p.m..  Morning and afternoon refreshment breaks would also be provided.

 

 

 

REGISTRATION CANCELLATION

ERISAclaim.Com will accept cancellation requests for refund made in writing at least 10 days prior to seminar dates.  Otherwise no refund will be issued, but registration fee can be used for any future seminar.  ERISAclaim.com will refund registration fee if the seminar is canceled.

 

 

 

TRAVEL INFORMATION

The Seminar site is not associated with any hotels, therefore you need to make your hotel arrangement accordingly with your travel plans.  Some reference travel web sites are listed on ERISAclaim.com

 

 

 

QUESTIONS

 

Call or E-Mail Jin Zhou at ERISAclaim.com

 

Tel: (630) 736-2974 (office);

 

Mobile: (630) 523-2190  (Seminar day contact only)

 

E-Mail:   ERISAclaim@aol.com

 

 

 

THE PURPOSE OF THIS SEMINAR

 

Problem Oriented and Maximal Reimbursement

Through Compliant Appeals After Wrongful Denials

 

  1. After you have already received denials, what must you do?
  2. Not documentation or coding, it's too late;
  3. You must appeal!!!
  4. For employer-sponsored plans, you must do ERISA appeals per US Supreme Court
  5. For Medicare, new Medicare appeal rules

 

 

 

For Fax Registration
Click here to Download PDF/Fax verion of Registration Form

 

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CHICAGO O'HARE INTERNATIONAL

OVERVIEW

 

DRIVING

 

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OVERVIEW

 

DRIVING

Midway Airport is about 10 miles from Chicago's downtown Loop.

 

 

Note: Due to high demand, our seminars in 2006 were booked more often by in-house sponsors and offered on other locations and announced by other sponsors. If you would like to book a on-site seminar for your organization, please contact us directly.

 

Dr. Jin Zhou will speak at "11th Annual Medical Billing National Conference" on May 10th, 2006 sponsored by Synergy Medical Information Systems and Electronic Network Systems on:

"Maximizing Healthcare Claim Reimbursement - Problem Oriented Appeals under ERISA"

 

"Mastering the 2006 Medicare Appeal Process"

 

 

 

Home ] Seminar Illinois ] Seminar North Carolina ] Seminar Pennsylvania ] Seminar Virginia ] Seminar Ohio ] Seminar SD ] Past Seminars ]

Department of Labor

 

 

AMNews through  AMA

Health plans subject to new federal appeals rules
Much-postponed regulations offer patients and doctors fairer and faster review, plus new rights, Dept. of Labor says.

 

 

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

        Selected links:

Sec. 1002.
Definitions

Sec. 1003.
Coverage

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

 

US Code Home

CHAPTER 18--EMPLOYEE RETIREMENT INCOME SECURITY PROGRAM

 

 

Code of Federal Regulations

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.

 

 

 

ERISA Laws/Rules

ERISA in the United States Code: Cross-reference table, table of contents

 

ERISA in US CODE

 

ERISA & Health Claim
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."

 

 

 

 

New HIPAA Privacy and ERISA Claims Review Rules: 10 Reasons To Comply (Brown Rudnick Berlack Israels L.L.P.)
 

Group Health Plan Compliance with ERISA and HIPAA: Navigating the Legal and Administrative Maze (PDF) (Brown Rudnick Berlack Israels L.L.P.)

72 pages. A 'Question and Answer Resource Guide."

 

 

Report of the ERISA Advisory Council's Working Group on Fiduciary Education and Training (U.S. Department of Labor, Employee Benefits Security Administration)

Excerpt: "We strongly urge anyone interested in the issue of fiduciary education to read through the transcripts of our work group's hearings ..."

 

 

 

State Prompt Pay Law Does NOT Work for Private Group Health Plans

Physicians Nationwide Are Confused!!!
 

Gilbert v. Alta Health & Life Insurance Co. (11th Cir. No. 01-10829,12/27/01).

 

""Because the insurance policy covered at least one other employee of Winfield Monument Company, besides Gilbert and his wife, there is no dispute that it constituted an ERISA plan."

 

American Benefits Council

Boehner Urges DOL to Delay New Claims Procedure Regulation for Group Health Plans (PDF)

"Specifically, we are concerned about provisions in the final rule that go even further

than the patients' rights bills passed by the Congress. For example, the Department's

final rule:..."

 

NAIC News Release

 

ERISA v State Laws

 

 

 

 
Working Families' Health Insurance Coverage, 1997-2001 (Center for Studying Health System Change)
 

"Of the 189 million nonelderly people in working families in 2001, 77.5 percent, or 146 million, had employer coverage,.."

 

Definitions of Health Insurance Plans and Other Terms (Federal Government’s Interdepartmental Committee)

 

 

 

AMA AMNews
Health plan on trial: Decisions bring responsibility
A New York lawsuit presents a major test of how health plans can be held accountable for their treatment decisions. -

 

$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.

 

 

 

 

Department of Labor

 

 

 

Peer Review

 

 

Independent Medical Review Experiences in California (California HealthCare Foundation)

 

Office for Civil Rights - HIPAA

OCR Guidance Explaining Significant Aspects of the Privacy Rule- December 4, 2002

 

HHS ISSUES NEW FREQUENTLY-ASKED QUESTIONS ON AUTHORIZATIONS UNDER HIPAA PRIVACY RULES, (FAQs) (Updated Sept. 24, 2003)

 

DOL Compliance Assistance for Health Plans

 

 

 

 

 

Federal Employees Health Benefits Program

 

FEHB HANDBOOK

 

 

Few California Residents, Providers Aware of Law on Independent Review of Health Plan Decisions (KaiserNetwork.org)

 

Independent Medical Review Experiences in California (California HealthCare Foundation)

Independent Medical Review, Phase I (369K)Download Now

Independent Medical Review, Phase II (832K)Download Now

 

Excerpt: "Many managed care patients and physicians in California are unaware of a state program that allows patients to appeal the decisions of their health plans, according to a report issued last week by the California HealthCare Foundation, the Los Angeles Times reports."

 

"The report recommended that the state DMHC develop a "how to" guide about the independent review program and distribute the guide in physician offices and employer human resource departments to increase participation. The report also recommended a campaign to explain the program to physicians and establish a system to ensure that health plans implement the decisions of the independent review board "in a timely manner," the Times reports."

 

 

2003 Segal Health Plan Cost Trend Survey: Preliminary Findings (PDF) (The Segal Company)

 

Tiered Hospital Plans (07/29/2003) (

 

Tiered Networks for Hospital and Physician Health Care Services (Employee Benefit Research Institute)

 

Retiree Health Care Benefits: Data Collection Issues (07/29/2003)

 

Facts from EBRI: Health Insurance and the Elderly (PDF) (Employee Benefit Research Institute)

 

Excerpt: "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)

 

the Foundation for Health Coverage Education (The Foundation for Health Coverage Education)

 

FAQ/Glossary, Member Services, Preferred Health Network, PHN Online,( CareFirst BlueChoice, Inc.)

DOL ERISA Talking Points

 

 

US Department of Justice Seal

USDOJ

 Office of the Deputy Attorney General:

Publications and Documents

 

 

USDOJ: DAG: Corporate Fraud Task Force

 

Federal Bureau of Investigation - Health Care Fraud Unit  

FBI: About the Health Care Fraud Unit

 

VideoVIDEO

 

Link to Site Map

 

Fighting Fraud & Abuse

 

 

Program Integrity Manual (PIM)

 

Examples of Fraudulent Activities

 pdf | word |

 

HHS-Office of Inspector General (OIG)

HHS-OIG-What's New

HHS-OIG-Fraud Prevention & Detection

HHS-OIG - Publications

Advisory Opinion 03-12 PDF (concerning a proposed joint venture between a medical center and a radiology group to own and operate an outpatient open magnetic resonance imaging facility)

 

Bureau of Justice Statistics Medical Malpractice Trials and Verdicts in Large Counties, 2001  (Acrobat file)

(Press release)

 

 

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)

 

Table of Contents - Health Care Fraud: Enforcement and Compliance - LawCatalog.com

 

PROSECUTING AND DEFENDING HEALTH CARE FRAUD CASES, WITH 2003 CUMULATIVE SUPPLEMENT (Author(s):  Michael K. Loucks and Carol C. Lam)

 

HEALTH CARE FRAUD AND ABUSE: PRACTICAL PERSPECTIVES, WITH 2003 SUPPLEMENT

 

Staying Out of Jail Under ERISA's Bulked-Up Criminal Law Penalites (Attorneys Russell D. Shurtz and Craig R. Pett)

 

 

 

 

FDA Logo links to FDA home page

New Super Search

 

 

 

FDA > CDRH > Database Super Search

 

"Device Listing Database

 

Proprietary Device Name:

MASSAGER ( THERAPUTIC, ELECTRIC, WATER

Common/Generic Device Name:

ASOOTHE/AQUAMED

Classification Name:

MASSAGER, THERAPEUTIC, ELECTRIC

Device Class:

1

Product Code:

ISA

Regulation Number:

890.5660

Medical Specialty:

Physical Medicine"

 

Categorization of Investigational Devices

 

"... all FDA-approved IDE's into either Category A (experimental / investigational) or Category
B (nonexperimental/ investigational). An experimental / investigational ..."

 

 

 

Seminar Schedules in ILNC, PA, VA, OH, Teleconference

 
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Phone (630) 736-2974 - Fax (630) 736-1439

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