2009 GUIDE TO New Medicare Claims Appeals Process CD Book: $395 New IL WC Laws For Healthcare Providers (with New Forms) CD Book: $275 Holiday Special -  Medicare New Appeal CD & IL WC CD: $460 [More info on CD Books]       [Order CD Book]

Fact Sheet - EBSA Achieves Total Monetary Results Exceeding $1.7 Billion

 (DOL, January 2006)

"Through its enforcement of the Employee Retirement Income Security Act (ERISA), the Employee Benefits Security Administration (EBSA) is responsible for ensuring the integrity of the private employee benefit plan system in the United States. EBSA’s oversight authority extends to approximately 730,000 pension plans and another 6 million health and welfare plans. These plans cover approximately 150 million workers and their dependents and include assets of more than $4 trillion.......

 

Record $88.4 Million Restored to Workers through Informal Complaint Resolution

 

When workers experience a problem with an employee benefit plan, EBSA has proven effective in resolving their requests for assistance. In FY 2005, EBSA’s Benefits Advisors handled nearly 160,000 inquiries and recovered $88.4 million in benefits on behalf of workers and their families through informal resolution of individual complaints. Many of these inquiries were received via EBSA’s toll-free number: 1.866.444.EBSA (3272) and Web site: www.askebsa.dol.gov.

 

These inquiries are also a major source of enforcement leads. When EBSA becomes aware of repeated complaints with respect to a particular plan, employer, or service provider, or when there is information indicating a suspected fiduciary breach, the matter is referred for investigation. In FY 2005, 1,067 new investigations were opened as a result of referrals from Benefits Advisors."

U.S. Court of Appeals for the D.C. Circuit to All Chiropractors

NO Appeal, No Lawsuit!!!

Amer Chiro Assn Inc vs. Leavitt, Michael O.

Released: 12/13/2005

"The jurisdictional question is more complicated. “No action against the United States, the [Secretary of Health and Human Services], or any officer or employee thereof shall be brought under [28 U.S.C. §] 1331 . . . to recover on any claim arising under” the Medicare Act. 42 U.S.C. §§ 405(h), 1395ii. Judicial review may be had only after the claim has been presented to the Secretary and administrative remedies have been exhausted. See 42 U.S.C. §§ 405(g), (h), 1395w-22(g)(5); Shalala v. Ill. Council on Long Term Care, Inc., 529 U.S. 1, 8-9 (2000); Heckler v. Ringer, 466 U.S. 602, 614-15 (1984); Weinberger v. Salfi, 422 U.S. 749, 763-64 (1975). This bar against § 1331 actions applies to all claims that have their “standing and substantive basis” in the Medicare Act. Ill. Council, 529 U.S. at 11, 17 (quoting Salfi, 422 U.S. at 761); see also Ringer, 466 U.S. at 615....."[page 5 of 8]

 

 

"To have such a claim heard, an enrollee could obtain the services of a chiropractor without first obtaining a referral. After the HMO refuses coverage because of the absence of a referral, the enrollee could file a grievance with the HMO, claiming that the referral requirement was illegal. See 42 U.S.C. § 1395w 22(g)(1)(A); 42 C.F.R. §§ 422.562(a)(1), .566(a). This would trigger the administrative process, at the end of which is judicial review of the Secretary’s final decision. See 42 U.S.C. § 1395w-22(g)(5); 42 C.F.R. § 422.612(a), (c). The chiropractor who provided the service could also mount an administrative challenge by “waiv[ing] any right to payment from the enrollee” and becoming the enrollee’s assignee. 42 C.F.R. § 422.574(b)." [page 6 of 8]

 

 

2009 GUIDE TO

New Medicare Claims Appeals Process

© 2005-6, Jin Zhou, ERISAclaim.com

---------------------

Enforcement News from DOL
Plan Administrator Indicted for Filing False Annual Reports With DOL DOL Sues Former Minneapolis Executives For Health Plan Mismanagement DOL Sues to Recover Funds for Tennessee Health Plan

"Aggressive oversight and new improvement efforts have cut the number of improper fee-for-service Medicare claims payments by half in one year, from 10.1 percent in 2004 to 5.2 percent in 2005, a $9.5 billion reduction in improper payments......"

 

2005 Advisory Opinions
AO/Date/Reference	2005-16A, 06/10/2005, ERISA Sec. 503
Recipient	Dr. Gary Conant Conant Chiropractic Clinic
Description of Request	Regarding the claims procedure regulation at 29 CFR 2560.503-1(h)(3) which requires the plan's named fiduciary deciding an appeal of a group health claim denied based on a medical judgment to consult with a physician or other health care professional that is licensed, accredited or certified to perform specified health services consistent with State law.

1. ERISAclaim.com - New! On-site Programs for ERISA & New CMS/Medicare Compliance

2. ERISAclaim.com: An Unique Magic for Integrated Health Systems

3. ERISAclaim.com - ERISA, Who?

4. ERISAclaim.com - ERISA 1-2-3

5. ERISAclaim.com - HSA &/Or  ERISA? 95% of HSA Are Still ERISA's!

6. ERISAclaim.com - Rx for GM $5.6 Billion Health-care Crisis with 50% Savings

7. ERISAclaim.com - CMS New Appeal Rules: "Overhaul of the Medicare Claims Appeals System"

 

Medicare CD-Book - $250 (April-May Special Discount $50) Click on the picture for more details on Order page

New U.S. Treasury -HSA FAQs Has Grown from 58 to 85, Under Eight Topic Headings (Links to U.S. Treasury)
U.S. Treasury -HSA Frequently Asked Questions The Basics of HSAs Who Can Have an HSA? Contributing to an HSA Using Your HSA Setting Up Your HSA Managing Your HSA Employer Participation in HSAs Trustees/Custodians Have further questions about Health Savings Accounts? E-mail us at HSAinfo@do.treas.gov or call (202) 622-4HSA.	HSA Home   FAQs   Technical Guidance   IRS Forms   HSA Basics   Press Releases   About HSAs   Contacts   Resources

Discount for March 2005: $35   $450 ERISA CD Book ERISA Claim Appeal Books & Systems Click here or the CD-Picture to enter our Secured Online Order page

With New 2005 Update (including New ERISA Assignment Form Required for ERISA Appeals, DOL, FAQ, B2-3)

Department of Law 120 Broadway New York, NY 10271   Department of Law The State Capitol Albany, NY 12224     For More Information: 518-473-5525 For Immediate Release  February 10, 2005 HEALTH PLANS AGREE TO PROVIDE REQUIRED COVERAGE INFORMATION "Attorney General Eliot Spitzer said today that 21 health plans operating in New York have agreed to take new steps to ensure that consumers have the information they need to intelligently shop for health coverage and obtain medically necessary care.   Under the agreements, the health plans have pledged to be more responsive to requests from consumers for so-called "clinical review criteria," which is used to determine whether health care claims will be covered. In the past, health plans have sometimes failed to disclose these criteria and other essential coverage information, discouraging access to needed care......   The clinical review criteria are extremely important to consumers with existing medical conditions because they contain the standards that the health plans use to determine whether a specific treatment is medically necessary; if not, coverage is denied and the consumer is left with the choice of either foregoing medical care or paying out-of-pocket. The State Managed Care Consumer Bill of Rights requires health plans to disclose these criteria to both current and prospective enrollees upon written request....."   02/10/05 Health Plans Agree to Provide Required Coverage Information (click for complete official press release)   NEW YORK HEALTH PLANS PARTICIPATING IN SETTLEMENT Aetna US Healthcare Atlantis Health Plan Capital District Physicians' Health Plan (CDPHP) CIGNA Healthcare of New York ConnectiCare of New York Empire HealthChoice Excellus Health Plan Group Health Inc. (GHI) HealthFirst New York Health Insurance Plan of Greater New York (HIP) Health Net of New York HealthNow New York Horizon Healthcare of New York Independent Health Association MDNY Healthcare MVP Health Plan Oxford Health Plans of New York Preferred Care United Healthcare of New York Vytra Health Plans WellCare of New York   Attachment: New York Managed Care Consumer Bill of Rights Compliance Survey

Text: Employee Benefits in Private Industry in the United States, 2002-2003 (PDF) (Bureau of Labor Statistics, U.S. Department of Labor)

 

 

12/18/2004: President's Radio Address, (http://www.whitehouse.gov)

"Another challenge in our economy is the rising cost of health care. More than half of all uninsured Americans are small business employees and their families. And while many business owners want to provide health care for their workers, they just can't afford the high cost. To help more Americans get care, we need to expand tax-free health savings accounts, which are already making a difference for small businesses and families. We should encourage health information technology that minimizes error and controls costs. And Congress must allow small firms to join together and buy health insurance at the same discounts big companies get."

Subject: President's Radio Address: Bush, ERISA, Health care??? Date: 12/19/2004 4:05:31 PM Central Standard Time To: "president@whitehouse.gov,vice.president@whitehouse.gov"   President's Radio Address http://www.whitehouse.gov/news/releases/2004/12/20041218.html "Another challenge in our economy is the rising cost of health care.  More than half of all uninsured Americans are small business employees and their families.  And while many business owners want to provide health care for their workers, they just can't afford the high cost.  To help more Americans get care, we need to expand tax-free health savings accounts, which are already making a difference for small businesses and families.  We should encourage health information technology that minimizes error and controls costs.  And Congress must allow small firms to join together and buy health insurance at the same discounts big companies get."  Dx & Rx for "the rising cost of health care":    HSA + ERISA + PPO = 5 X $1.8 Trillions for US healthcare/year!!!.   "tax-free health savings accounts" = HSA   "Congress must allow small firms to join together" = ERISA/MEWA/State Law Pre-emption   "buy health insurance at the same discounts big companies get." = PPO di$count= Medical Inflation   GAO: Current and Emerging Fiscal and Retirement Security Challenges, American Benefits Council/MetLife Conference, Washington, DC, on January 14, 2005   Rising Health care Costs Have Many Implications (Direct) Rising Healthcare Costs Have Many Implications (Indirect)   ERISAclaim.com - A $1.0 Trillion Nuclear Solution to U.S. Health-care Crisis & $44 Trillion Budget Deficits http://erisaclaim.com/healthcare_crisis_turnaround.htm   ERISAclaim.com: "Failure of Imagination" Again? U.S. Health-Care Disaster http://erisaclaim.com/failure_of_imagination.htm     Jin Zhou ERISAclaim.com 630-736-2974

 

 

Opinion: Top Ten Health Policy Initiatives in 2005 (Galen Institute)

 

Changes in Workers' Compensation in 2004 (PDF) (U.S. Bureau of Labor Statistics)

 

Court Rules Indiana Marketing Firm and Executives Must Restore Losses to Health Plan (DOL Media Release, 01/05/2005)

"Chicago, Illinois - A federal district court in Indiana has ordered TRG Marketing, LLC of Indianapolis, Indiana, and its executives to restore losses to the firm’s health plan, pay unpaid health claims owed to plan participants nationwide, and be permanently barred from serving as plan fiduciaries, according to a judgment obtained by the U.S. Department of Labor. The judgment resulted from a lawsuit in which the department alleged that TRG executives diverted up to $3.4 million in health plan assets to pay personal expenses for themselves and family members.......

 

Under the judgment, TRG, William Paul Crouse and Carmelo Zanfei were removed from their positions with the TRG health plan and are permanently barred from service in the future to any plan governed by the Employee Retirement Income Security Act (ERISA). The court found that the defendants engaged in self-dealing when they used health premiums collected from employers to pay for commissions to TRG’s enrollment brokers, trips overseas, expensive glassware, personal expenses, charitable contributions, and a corporate line of credit. A trial will be held to determine the amount to be repaid by the defendants...."

 

Chao v Crouse
    Cause No. 1:03-cv-1585-TAB-DFH 

11/22/04

HEALTH CARE SPENDING IN THE UNITED STATES SLOWS FOR THE FIRST TIME IN SEVEN YEARS (CMS News, January 11, 2005) Detailed national health spending estimates are available at http://www.cms.hhs.gov/statistics/nhe/default.asp   Expenditure estimates for 1960-2003 **Highlights  **Tables   **Pie Charts  **Data files for downloading

 

HHS UPDATES PRIVACY FAQs - EXPLAINING PERMITTED USES AND DISCLOSURES OF PHI IN LITIGATION (Updated Jan. 14, 2005)

9 Answers Updated: Judicial and Administrative Proceedings      Subject    1 New - May a covered entity that is a party in a legal proceeding use or disclose PHI for the litigation? 2 New - May PHI be disclosed in response to a subpoena or discovery request absent a court order? 3 New - May a covered entity use or disclose protected health information for litigation? 4 New - What “satisfactory assurances” are required before responding to a subpoena without a court order? 5 New - When must a covered entity account for disclosures of PHI made during the course of litigation? 6 New - For legal proceeding disclosures, can notice be given to the individual's lawyer? 7 New - Must lawyer-business associates require others to agree to the privacy conditions that apply to the lawyers? 8 New - May a covered entity disclose protected health information in response to a court order? 9 New - For legal proceeding disclosures, when is a copy of the subpoena sufficient satisfactory assurance of notice?

 

Hospital CEO's Confessed Their Biggest Headaches: Financial Challenges from Unpaid/Denied Medical Bills in 2004

71% of CEO's, out of 460 surveyed by American College of Healthcare Executives (ACHE) in 2004, identified No. 1 headache, among other things, as financial challenges. Top 5 problems of financial troubles:  Medicaid 78%, Bad Debt 72%, Medicare 70%, Revenue Cycle Management 53% and Managed-care Payments 52%. Care for the uninsured and personnel shortage were ranked as No. 2 and No. 3 pressing issues. For more details, go to ACHE's Top Issues Confronting Hospitals: 2004 Dr. Jin Zhou, President of ERISAclaim.Com, has strongly advocated for the Hospital CEO's and the entire health care industry to utilize and comply with the superpower of ERISA, federal law, governing health care denials and to create a new line of occupation, claim appeals specialist, to cope with industry claim denial crisis, soon to be tripled in 2005.

 

HHS Issues Final Regulation on Access to Group Health Coverage (12/29/2004, HHS)

 

Text of Final HIPAA Portability Regulations (PDF) (Internal Revenue Service, Employee Benefits Security Administration, Centers for Medicare & Medicaid Services)

 

Text of Proposed HIPAA Portability Regulation Modifying Break in Coverage, Special Enrollment Period (PDF) (Internal Revenue Service, Employee Benefits Security Administration, Centers for Medicare & Medicaid Services)

 

FOR IMMEDIATE RELEASE THURSDAY, DECEMBER 30, 2004 WWW.USDOJ.GOV   #807: 12-30-04 HEALTHSOUTH TO PAY UNITED STATES $325 MILLION TO RESOLVE MEDICARE FRAUD ALLEGATIONS

"WASHINGTON, D.C. - HealthSouth Corporation, the nation's largest provider of rehabilitative medicine services, has agreed to pay the United States $325 million to settle allegations that the company defrauded Medicare and other federal healthcare programs, the Department of Justice announced today."   HHS-OIG-Corporate Integrity Agreements

 

 

CMS News on Wheelchair and Medical Necessity

December 15, 2004: MEDICARE OPENS NATIONAL COVERAGE DETERMINATION TO MAKE SURE BENEFICIARES WHO NEED WHEELCHAIRS GET THEM   October 18, 2004: MEDICARE BENEFICIARIES WILL SOON BE ABLE TO RESOLVE MEDICARE APPEALS FASTER “We are working toward completing our overhaul of the Medicare claims appeals system by October 1, 2005 to better serve Medicare beneficiaries, providers, physicians, and other health care providers.” "Other steps that CMS is taking as part of its comprehensive overhaul of Medicare claims appeals include: Finalizing the transfer of responsibility for the third level appeals conducted by Administrative Law Judges from the Social Security Administration to the Department of Health and Human Services by October 1, 2005. Developing a new appeal-specific data system that will allow authorized users to track  individual appeals in real time. Establishing an Administrative QIC that will oversee the distribution of case-files, develop appeals processing protocols, conduct training of the QICs, and the dissemination of information on QIC appeals decisions to the public.  Implementing a 60-day decision deadline and improved notices for claims redeterminations, or first-level appeals performed by fiscal intermediaries and carriers.   The improved notices will include the specific reasons for the decision and a summary of relevant clinical or scientific evidence used in making the decision. Issuing the final regulations needed to implement the new uniform appeals procedures,  including the rules QICs and other appeals entities by the end of the year."   Maximum Comfort, Inc v. Tommy G. Thompson (06/30/2004, United States District Court for the Eastern District of California)   RenCare Ltd vs. Humana Health Pln TX (5th Cir. 12/30/2004)

 

 

Money, Where??$

December 03, 2004: NEW CMS STUDY SHOWS MEDICARE, MEDICAID PAID FOR MORE THAN HALF OF ALL SENIOR HEALTH CARE   Age Estimates in the National Health Accounts (pdf), Sean P. Keehan, Helen C. Lazenby, Mark A. Zezza, and Aaron C. Catlin   National Health Accounts: Age Estimates, Personal Health Care in selected years   MEDICARE OVERPAYMENTS REACHED NEARLY $20 BILLION IN 2003, NEW SURVEY FINDS (PharmExec)   CMS ANNOUNCES IMPROVED EFFORTS TO REDUCE MEDICARE PAYMENT ERROR RATES (12/13/2004, CMS Press Release)

 

Medicare Modernization Update-Released and Pending Manual Instructions (RELATING TO APPEALS)
921	Provider Education and Technical Assistance
931	Transfer of Responsibility for Medicare Appeals
932	Process for Expedited Access to Review
933	Revisions to Medicare Appeals Process
934	Prepayment Review
935	Recovery of Overpayments
937	Process for Correction of Minor Errors and Omissions without Pursuing     Appeals Process
939	Appeals by Providers when there is no Other Party Available
940	Revision to Appeals Timeframes and Amounts
940A	Mediation Process for Local Coverage Determinations
952	Revisions to Reassignment Provisions
TITLE III—COMBATTING WASTE, FRAUD, AND ABUSE 301  Medicare Secondary Payor (MSP) Provisions
CMS: Contact Your Carrier/Fiscal Intermediary   via Toll-Free Numbers and Websites -- A listing of the new toll free numbers that CMS has installed at Medicare contractor sites

 

PPO Fee Splitting: Vince Street Clinic v. Healthlink, Inc. No. 4-03-0876, (The Illinois Appellate Court, 4^th District,)

"This case presents the question whether a company that creates a list of health-care providers that it makes available for a charge to members of health plans may enter into an agreement under which the health-care providers themselves would pay to be included on the list. We conclude the agreement improperly requires physicians to pay a fee for the referral of patients."

AMNews: New Jersey doctors sue insurer over forced payback ... American Medical News (Jan. 3/10, 2005)

 

Doctors sue to block $15 million repayment (Newark Star Ledger, NJ - Nov 29, 2004)

 

N.J. Medical Society Goes to Court To Block Recoupment of $15M in Alleged Overpayments (11/30/2004, AP via Insuarnce Journal)

"The Medical Society of New Jersey is seeking court action to prevent an insurance company from recouping $15 million in alleged overpayments to doctors.

 

The society is seeking an injunction against Horizon Blue Cross/Blue Shield, which claims that over two years it overpaid more than 600 doctors who performed heart procedures. The insurer has asked the physicians to give back the money by Nov. 30."

[doc] Press Release: Horizon Agrees To Temporarily Halt Efforts To Recover Money From State’s Cardiologists As A Result Of MSNJ Lawsuit, 12-09-2004

Assemblyman Neil Cohen's Letter (pdf)

Some health care costs unnecessary (APP.COM)

 

"In recent months, Horizon has seen a dramatic increase in the number of claims it is receiving, Marino said. New Jerseyans, he said, are receiving more health care yet, "the higher volume of services does not translate into improved quality."

GAO: The Future Sustainability of Social Insurance Programs (David M. Walker, Comptroller General of the United States)

• (Cont'd)Social Security and Health Spending as a Percent of GDP

• Current Fiscal Policy Is Unsustainable

• We Need a 3-Pronged Approach

• 21st Century Questions

• 21st Century Questions (Cont'd)

A.M. Best Special Report: Moderating Costs Favorably Impact Health Insurers' Earnings

"Helped by lower-than-expected health care cost increases, managed care companies’ net income increased by 40.3% for the first nine months of 2004, according to a report by Oldwick, N.J.-based A.M. Best Co. The 15 largest managed care companies reported total profits of $6.17 billion for the nine months ending Sept. 30, 2004, compared with $4.40 billion in the year-earlier period. "

Life and Health Insurers' Profits Skyrocket 213% in First Quarter 2004, Highest Increase in Decade, According to Weiss Ratings (BUSINESS WIRE)--Sept. 22, 2004