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Breaking News
from Federal Court
On
Overpayment Crisis
Insurance News - Pomerantz Haudek Grossman & Gross LLP
Announces That Court Permits Provider ERISA Class Action to
Proceed Against Blue Cross Blue Shield Companies for Improper
Overpayment Demands and Forced Recoupment
Pomerantz
Haudek Grossman & Gross LLP Announces That Court Permits Provider
ERISA Class Action to Proceed Against Blue Cross Blue Shield
Companies for Improper Overpayment Demands and Forced Recoupment
"NEW
YORK, May 25, 2010 (GLOBE NEWSWIRE) -- Pomerantz Haudek Grossman &
Gross LLP (the "Pomerantz Firm") today announced that the United
States District Court for the Northern District of Illinois upheld
claims filed under the Employee Retirement Income Security Act of
1974 ("ERISA") against 22 leading Blue Cross Blue Shield ("BCBS")
insurers across the country. The action was filed 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"), the Association of New
Jersey Chiropractors ("ANJC"), the Florida Chiropractic
Association ("FCA"), and the California Chiropractic Association
("CCA"). 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......
"This
is a landmark decision, with widespread implications for the
health care industry," says Jin Zhou, D.C. "Providers finally have
a means to fight back against insurance companies for making
invalid overpayment demands." Dr. Zhou is a national ERISA
consultant who, through his website, www.ERISAclaim.com, and
consulting services he offers to providers and plan sponsors, has
long advocated the use of ERISA to combat improper post-payment
audit activities.
"
For a Copy
of the Court Ruling
PA Chiro Assnt et al v. BCBSA et al
May 17, 2010
PORTER v. ANTHEM HEALTH PLANS
OF KENTUCKY, INC.
March 18, 2010
United States District Court, E.D. Kentucky, Northern Division,
Ashland.
A PPO participating
provider sued the Anthem for alleged wrongful overpayment
recoupment in the state court. "Defendant argues that this case
could have been brought under ERISA and is thus subject to federal
jurisdiction. The Court agrees."
The court mainly relied
upon the U.S. Supreme Court unanimous landmark decision in
Aetna
v. Davila, and ruled that PPO overpayment recoupment
dispute is 100% ERISA
business, not PPO business at all.
This is the latest and the
first federal court ruling for skyrocketing overpayment crisis in
U.S. healthcare system with a potential of $6 trillion in
overpayment dispute market. The provider class action lawsuits
under ERISA are expected
to explode in 2010.
ERISAclaim.com is the
only compliance consultant and publisher with ERISA compliant
Appeals Books and systems to effectively assist providers in appealing the alleged
overpayment demand and recoupment under ERISA:
New Free Webinars Announced to Discuss the
Latest Federal Court Overpayment Lawsuit Ruling and New Obama
Health Laws for the Skyrocketing $6 Trillion Overpayment
Recoupment Market 03-29-2010, Hanover Park, IL
The New ERISA Overpayment Appeals And
Anti-Fraud Services Announced For Healthcare Providers Through
ERISA Appeals And Anti-Fraud Compliance
02-08-2010, Hanover Park, IL
ERISAclaim.com: 2010 Appeal
Books & Systems for Maximal Reimbursement by Compliance
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PORTER v. ANTHEM HEALTH PLANS
OF KENTUCKY, INC.
March 18, 2010
United States District Court, E.D. Kentucky, Northern Division,
Ashland.
"In addition,
Plaintiffs' claim sounds in ERISA.
Absent ERISA, there
would be no obligation between the parties. Of note in
this regard is United
States Supreme Court decision in which participants in an
ERISA plan sued the plan administrators in tort, alleging injury
arising from the administrators' decisions to deny coverage for
certain treatments. Aetna Health, Inc.
v. Davilla, 542 U.S. 200 (2004). The Supreme Court
rejected the Plaintiffs' argument that the action sounded in
state tort law, finding that liability only exited because of
the ERISA plans that bound the parties. Id.
As in Davilla, that Porter and
his practice have a
provider contract with Anthem does not, in and of itself, create
an independent legal duty for Anthem to make payments to Porter.
What is payable, and, more importantly, what is not is
defined by the terms of the benefit plans and, thus, governed by
ERISA."
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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
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White House gives Congress two weeks to pass health-care bill
Washington Post
"White House press
secretary
Robert Gibbs is ratcheting up the pressure on Congress to complete
health-care legislation,
setting March 18 as the deadline by which a final bill should be
passed."
The New Healthcare Reform
Is Final on Provider Reimbursement Laws - ERISA Appeals
Procedures Mandatory for All Group Health Plans and Healthcare
Providers
01-04-2010, Hanover Park, IL
The Final Health Bill Passed In Senate
On Christmas Eve Is Completely Consistent With House Health Bill By
Incorporating ERISA Claim Regulation In Its Entirety For All Group
Health Plans Into Obama Health Reform, For 200 Million Americans
Under New Obama Universal Healthcare Laws. ERISA Appeal Process Is
Now Mandatory For All Group Health Plans And Healthcare Providers As
Well As Consumers. First Free Monthly ERISA Webinar starts on
01/18/2010, and First Advanced ERISA Claim Specialist Certification
Program Starts in Feb. 2010.
HR3962: Affordable Health Care for
America Act
HR3590: Patient Protection and
Affordable Care Act
Guest column: Congress
should restore workers' rights (DesMoinesRegister.com)
"ERISA
eliminates remedies that used to be available if your insurer denied
you coverage in bad faith. You could sue for damages to compensate you
for the ... ….At least 18,000 people die annually because their
health insurer won't cover the treatments they need to stay alive.”
The Insurance
Companies' "License to Kill": ERISA (10/27/2009,
OpEdNews
Douglas Drenkow)
"One of the most notorious cases in
which ERISA stood in the way of justice was that of California
teenager Nataline Sarkisyan. In 2007, the 17-year-old who ..."
License to Steal?
Embezzlement Recovery Services (ERS)
for Midsized and Large ERISA Health
Plans
ERISAclaim.com Press
Release
ERISAclaim.com
Announced The Nation's First Embezzlement Recovery Services for Large
ERISA Health Plans from the $6 Trillion Healthcare Denial Management
Market 10-23-2009, Hanover Park, IL
ERISAclaim.com Announced Free ERISA Webinar for Healthcare Overpayment
Dispute and Claim Denials in Response to Increasing High Demand from
the $6 Trillion Healthcare Denial Management Market
10-19-2009, Hanover Park, IL
ERISAclaim.com Announced the Expansion of Its ERISA Litigation Support
For the Healthcare Claims In Response to Increasing High Demand from
the $6 Trillion Healthcare Denial Management Market.
10-19-2009, Hanover Park, IL
ERISAclaim.com
Announced the Nation's First Certification Program for the ERISA
Claim Appeal Specialist for Healthcare Providers and Managed-Care
Payers,
10-13-2009, Hanover Park, IL
ERISAclaim.com
Announced 2010 ERISA Seminars for Healthcare Overpayment and Claim
Denial Appeals for the $6 Trillion Healthcare Denial Management
Market.
10-14-2009, Hanover Park, IL
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NBC 10 Breaking News:
Overpayment - FBI - Class
Action
"One of the Largest Fraud in US
History"
NBC10 Video
$412,951.93
Overpayment Recoupment |
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
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
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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
|
04/18/2009:
ERISAClaim.com - Overpayment & SIU in 2009, $1
Trillion Healthcare Bailout & Foreclosures
"Hospitals and health-care providers have
been in
$1 trillion foreclosure in 2009 as healthcare industry bailout
by SIU ( Special Investigation Unit) from every healthcare plan payors,
managed-care network operators and even Medicare (RAC, Recovery
Auditing Contractor). This kind of sophisticated healthcare provider
foreclosure has been carried out, politically correctly, as anti-fraud
or abuse prevention program, while more than 95% of
$1 trillion
overpayment "takeback" or recoupment are truly retrospective benefits
denials."
The White House News: New ERISA Chief for USA:
"Phyllis C. Borzi, Nominee for Assistant Secretary of Labor
for Employee Benefits Security, Department of Labor"
Excerpt: "Until January 1995, [Phyllis] Borzi served as pension and employee
benefit counsel for the U.S. House of Representatives, Subcommittee on
Labor-Management Relations of the Committee on Education and Labor. She was
on the Committee staff for 16 years. . . . . Borzi has published numerous
articles on ERISA, health care law and policy and retirement security issues
and is a frequent speaker on programs sponsored by legal, professional,
business, consumer and state and local governmental organizations. An active
member of the American Bar Association, Borzi is the current chair of the
ABA's Joint Committee on Employee Benefits . . . ."
Excerpt: "President Obama on Tuesday during a
prime-time news conference linked issues within the U.S. budget in
part to high health care costs, stating that 'almost every single
person' who has examined the nation's budget has concluded that the
government must find a way to reduce health care costs, the Washington
Post reports (Shear/Wilson, Washington Post, 3/25)."
Comments from Jin Zhou:
Fixing healthcare without addressing ERISA,
the law 100% governing more than 90% of non-Medicare claims in USA, is
Impossible - Jin Zhou
ERISA laws will be definitely enforced by this new ERISA Chief.....
ERISA appeals and practice will mean more than ever before....
New 2009 ERISA Ruling from
SUPREME COURT OF THE UNITED STATES
KENNEDY, EXECUTRIX OF THE ESTATE OF KENNEDY,
DECEASED v. PLAN ADMINISTRATOR FOR DUPONT
SAVINGS AND INVESTMENT PLAN ET AL.
For more info
http://www.erisaclaim.com/Suprem_Court.htm
Breaking News
in 2009 for Healthcare Reimbursement
© JIN ZHOU, President,
ERISAclaim.com
Jan. 13, 2009
on January 13, 2009,
Attorney General Cuomo
Announces Historic Nationwide Health Insurance Reform; Ends Practice Of
Manipulating Rates To Overcharge Patients By Hundreds Of Millions Of Dollars.
The industry wide UCR scam is the biggest consumer fraud of the Century with
conflict of interest
on January 8, 2009,
California Supreme Court ruled that
healthcare provide must appeal claim denials on UCR to HMO, health plans,
under ERISA for ERISA regulated employer-sponsored plans. health-care
providers may not balance bill HMO patient. HMOs may not simply reimburse
healthcare providers at the Medicare rate.
More than 80% of non-Medicare claims
in USA are ERISA claims, and "Seventy percent of insured working Americans
pay higher premiums for insurance plans that allow them to use
out-of-network doctors."
In the worst economic crisis for 2009,
healthcare providers must learn and do ERISA and Medicare claim appeals, or
be out of business.
NY AG's Settlement Press Release and California Supreme
Court Ruling are captioned below with color-coded notation.
If you have any questions, please contact Dr. Jin Zhou,
the president of the ERISAclaim.com at
ERISAclaim@aol.com.
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01/13/2009
Attorney General Cuomo Announces
Historic Nationwide Health Insurance Reform; Ends Practice Of Manipulating
Rates To Overcharge Patients By Hundreds Of Millions Of Dollars
Industry-Wide Reform of
Reimbursement System Will End Conflicts of Interest and Create Fair
Rates for Consumers Nationwide
NEW YORK, NY
(January 13, 2009) – Attorney General Andrew M. Cuomo today
announced historic reform of the nationwide health care
reimbursement system that will end conflicts of interest and
generate fair reimbursement rates for working families nationwide.
Cuomo has reached an agreement with UnitedHealth Group Inc. (NYSE:
UNH) (“United”), the nation’s second largest health insurer, after
conducting an industry-wide investigation into
a scheme to defraud consumers by manipulating reimbursement rates.
At the center of the
scheme is Ingenix, Inc. (“Ingenix”), a
wholly-owned subsidiary of United, which is the nation’s largest
provider of health care billing information. Under the agreement
with United, the database of billing information operated by Ingenix
will close. United will pay $50 million
to a qualified nonprofit organization that will establish a new,
independent database to help determine fair out-of-network
reimbursement rates for consumers throughout the United States.
“For
the past ten years, American patients have suffered from
unfair reimbursements for critical medical
services due to a conflict-ridden system that has been owned,
operated, and manipulated by the health insurance industry.
This agreement marks the end of that flawed system,” said Attorney
General Cuomo. “As working families throughout our nation struggle
with the burden of health care costs, we will make sure that health
insurers keep their promise to pay their fair share. The industry
reforms that we announce today will bring crucial accuracy,
transparency, and independence to a broken system.
During these tough economic times, this
agreement will keep hundreds of millions of dollars in the pockets
of over one hundred million Americans.”
In February 2008,
the Attorney General announced an industry-wide investigation into
allegations that health insurers unfairly saddle consumers with too
much of the cost of out-of-network health care.
Seventy percent of insured working Americans pay higher premiums
for insurance plans that allow them to use
out-of-network doctors. In
exchange, insurers often promise to cover up to eighty percent
of the “usual and customary” rate of the
out-of-network expenses, and consumers are responsible for
paying the balance of the bill.
United and the
largest health insurers in the country rely on the United-owned
Ingenix database to determine their “usual and
customary” rates. The Ingenix database uses the insurers’
billing information to calculate “usual and
customary” rates for individual claims by assessing how much
the same, or similar, medical services would typically cost,
generally taking into account the type of service and geographical
location. Under this system, insurers control reimbursement rates
that are supposed to fairly reflect the market.
Attorney General
Cuomo’s investigation concerned allegations that the Ingenix
database intentionally skewed “usual and
customary” rates downward through faulty data collection,
poor pooling procedures, and the lack of audits.
That means many consumers were forced to pay
more than they should have. The investigation
found the rate of underpayment by insurers
ranged from ten to twenty-eight percent for various medical services
across the state. The Attorney General found that
having a health insurer determine the “usual
and customary” rate – a large portion of which the insurer then
reimburses – creates an incentive for the insurer to manipulate the
rate downward. The creation of a new database, independently
maintained by a nonprofit organization, is designed to remove this
conflict of interest.
Under Attorney General Cuomo’s
agreement with United:
 | United will pay
$50 million to establish a new,
independent database run by a qualified nonprofit organization;
|
| The
nonprofit will own and operate the new database, and will
be the sole arbiter and decision-maker with respect to all data
contribution protocols and all other methodologies used in
connection with the database; |
| The
nonprofit will develop a website where, for the first time,
consumers around the country can find out in
advance how much they may be reimbursed for common out-of-network
medical services in their area; |
| The nonprofit will make rate
information from the database available to
health insurers; |
| The
nonprofit will use the new database to conduct academic
research to help improve the health care system;
|
| The nonprofit will be selected
and announced at a future date. |
In February 2008,
Cuomo also announced that he had issued subpoenas to the nation’s
largest health insurance companies that use the Ingenix database,
including Aetna (NYSE: AET), CIGNA (NYSE: CI),
and WellPoint/Empire BlueCross BlueShield (NYSE: WLP). The Attorney
General’s industry-wide investigation is ongoing.
Cuomo continued,
“Our agreement with United removes the
conflicts of interest that have been inherent in the consumer
reimbursement system. This has been an industry-wide problem, and
it demands an industry-wide reform. We commend United for leading
the industry on this issue, and we encourage
other insurers to follow suit.”
Cuomo was joined by
representatives from United and from leading medical and consumer
organizations in making today’s announcement at the Saint Vincent
Catholic Medical Center in Manhattan.
“We are committed to
increasing the amount of useful information available in the health
care marketplace so that people can make informed decisions, and
this agreement is consistent with that approach and philosophy,”
said Thomas L. Strickland, Executive Vice President and Chief Legal
Officer of UnitedHealth Group. “We are pleased that a
not-for-profit entity will play this important role for the
marketplace.”
President of the American Medical Association
(AMA), Nancy Nielsen, M.D., said, “Today, patients and
physicians prevailed over health insurance giant UnitedHealth Group
when New York Attorney General Cuomo stopped the insurer from using
a rigged Ingenix database that increased insurer profits at the
expense of patients and physicians. The AMA appreciates the
leadership of Attorney General Cuomo in initiating his investigation
into the Ingenix database, and fully supports the Attorney General’s
actions to have a nonprofit entity create a new, reliable database
that is fair to patients and physicians.”
President of the
Medical Society of the State of New York (MSSNY) Michael H.
Rosenberg, M.D., said, “We thank Attorney General Cuomo for taking
decisive action to finally achieve one of the major goals of a
lawsuit that the Medical Society of the State of New York initiated
with two other medical societies over eight years ago. Because of
the thorough research and diligent negotiation of Mr. Cuomo and his
expert staff, patients and their physicians will no longer be
subject to inadequate out-of-network payments determined by the
flawed Ingenix database.”
Consumers Union
Programs Director Chuck Bell said, “Consumers
Union greatly appreciates the care that Attorney General
Cuomo and his staff have taken in investigating these issues, and
creating the careful architecture in this settlement. This is an
extremely sensible, fair solution, which will be of great benefit
for consumers nationwide. We appreciate the fact that United
Healthcare has come to the table to resolve these issues in a
comprehensive way, and we hope that other insurance companies will
quickly get on board, and strongly support this excellent plan to
improve transparency for out-of-network charges.” Consumers Union
is the nonprofit publisher of Consumer Reports.
Today, Cuomo also
issued a report on his investigation, “Health Care Report: The
Consumer Reimbursement System is Code Blue.” The report highlights
the conflicts of interest and other defects in the current system
and calls for the reforms announced today. It can be accessed at
http://www.oag.state.ny.us/bureaus/health_care/HIT/reimbursement_rates.html.
The agreement
announced today is the result of an investigation by Deputy Chief of
the Health Care Bureau James E. Dering, Senior Trial Counsel Kathryn
E. Diaz, and Assistant Attorneys General Brant Campbell and Sandra
Rodriguez, under the direction of Linda A. Lacewell, the head of the
Attorney General’s Healthcare Industry Taskforce. The Attorney
General expressed his appreciation to Steven E. Fineman, Esq., of
Lieff Cabraser Heimann & Bernstein, LLP, for his pro bono
services in this matter.
For more
information, including consumer tips for out-of-network care, or to
file a complaint, please visit
http://www.oag.state.ny.us/bureaus/health_care/HIT/reimbursement_rates.html."
**************************
2009 UCR in the Media
Health
insurer accused of overcharging millions - Health - TODAYshow.com
“This is a huge scam
that affected hundreds of millions of Americans [who were] ripped off by
their health insurance companies,” says Cuomo. “This was unethical, and it
robbed vulnerable patients of insurance reimbursements they deserved.”
“This is huge.
This problem went across the country,” Nancy Nielsen,
president of the American Medical Association, told the TODAY show. “It’s
industry-wide, throughout insurers. So, it touched every state. Many
doctors, many millions of patients, and this has been going on for years.”
$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
Unions Obtain Historic Health Care
Settlement for Members and ...
MSNBC - 8 hours ago
On Tuesday, New York Attorney General Andrew Cuomo
announced a settlement with United Healthcare in which a new and independent
database would be ...
Pomerantz
Announces $350 Million Settlement With United
Healthcare ...
MSNBC
© JIN ZHOU, President,
ERISAclaim.com
Jan. 16, 2009
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PROSPECT MEDICAL GROUP, INC., et al. v.
NORTHRIDGE EMERGENCY MEDICAL GROUP et al.
IN THE SUPREME COURT OF CALIFORNIA
Filed 1/8/09
"The Court of Appeal concluded that balance
billing is not statutorily prohibited. Second, it concluded that
Prospect is not entitled to a judicial declaration
imposing the Medicare rate as the reasonable rate. Third, it
concluded the trial court abused its discretion by denying leave to amend
the complaint to permit Prospect to allege that Emergency Physicians charged
more than a reasonable rate for a specific medical procedure."
"......we conclude that billing disputes over
emergency medical care must be resolved solely
between the emergency room doctors, who are entitled to a reasonable payment
for their services, and the HMO, which is obligated to make that payment.
A patient who is a member of an HMO may not be injected into the
dispute. Emergency room doctors may not bill the patient for the disputed
amount."
2009 UCR / HMO in the
Media
The California Supreme Court on Balance Billing and Healthcare ...
© JIN ZHOU, President,
ERISAclaim.com
Jan. 13, 2009
|
|
Dr. Jin Zhou (Joe) will Speak at
The
Business of Medicare Advantage: Forum 2009
by
WRG Research Inc
Afternoon Workshop E on Junauary 28,2009
January 28 - 30, 2009,
Washington, DC
Best
Practices for Operations, Revenue Management, Policy, Marketing,
Compliance, Strategy, Part D, SNPs and Dual Eligibles
Speakers -
Agenda at
Glance -
Who should Attend --
Why attend |
|
 |
-
Dr. Jin Zhou will be speaking at World
Research Group's
"Summit on Medicare
Advantage Reimbursement for Hospitals"
-
E-mail Your Questions to
ERISAclaim@aol.com
|
New 2007 ERISA Appeal
Major Updates ($95)
ERISAclaim.com
04/06/2007
New Denial
Crisis Demanding for New Solutions
for Your
Reimbursement Problems
In 2007, 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 2007, 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 Order?
Our new 2007 ERISA
Appeal Updates can be ordered for $95 by those who have previously
purchased our ERISA Appeal CD Book and Systems, and these
updates cannot be separately purchased without prior purchase of
ERISA Appeal CD Book and Systems for $450. However Our new 2007
ERISA Appeal Updates is free to those who have purchased ERISA
Appeal CD Book and Systems in past 30 days from
04/07/2007.
You may place your order
from our website, www.ERISAclaim.com on page of Appeal
Books and Systems at http://www.erisaclaim.com/products.htm
You may also call us at
630-736-2974 for a phone order or any questions |
|
New 2006
Appeal Letters (10/13/2006)
ERISA Appeal for
Overpayment Refund Request due to Medical Necessity and New PPO
Hearing
In accordance with
U.S. Supreme Court decision in Aetna Health Inc. v. Davila on
06/21/2004, “Medical necessity” dispute or denial and subsquent
overpayment request, is an ERISA plan retrospective administrative
remedy, and any non-ERISA “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),......"
New 2006
Appeal Letters (10/04/2006)
Due to the
increasing Katrina style of plan OverPayment Recoupment or
Recovery denials, when plans withhold or reduce countless subsequent
or future plan approved claim payments by alleging recoupment or
recovery for previously overpaid claims to providers, we have added to
our ERISA Appeal
Book & System the
most powerful ERISA appeal letter (OverPayment Recoupmet Appeal 2006)
based on all applicable
U.S. Supreme Court rulings,
2432 Coercive or Fraudulent Interference with
ERISA Rights -- 29 U.S.C. 1141 and new ERISA
claim regulation as well as our practical experience and knowledge in
ERISA appeal practice.
New 2006 Appeal Letters (09/28/2006)
We have added two new and
updated appeal letters to our ERISA Appeal CD Book for increasing
overpayment refund requests and disputes from health plans and commercial collection
companies.
Our new and updated appeal
letters are based on ERISA claim regulation on denials-adverse
benefits determination, two new
U.S. Supreme Court rulings in Aetna Health Inc. v. Davila
on 06/21/2006 and Sereboff v. Mid Atlantic Medical
Services on 05/15/200 as well as federal “Fair Debt
Collection Practices Act”.
Pricing for copyrighted
update letters: Free to anyone who purchased our ERISA Appeal
CD Book in past 60 days (please email us for free password). $35 for
anyone who purchased our ERISA Appeal CD Book prior to past 60 days.
Who may use our
online secured order page to pay for your order
and password, then download the
letters from our
"Appeal Book & System Page". We do not
sell these appeal letters separately from our
ERISA Appeal CD Book
($450). |
|
ABATIE V ALTA HEALTH &
LIFE
9th Cir. 08/15/2006
"In addition, this case requires us to consider
how a court is to review an ERISA plan administrator’s decision when
the procedure that produced the decision did not
follow all statutory requirements. For the reasons
that we will develop, we
conclude that when a decision by an
administrator utterly fails to follow applicable procedures,
the administrator is not, in fact, exercising discretionary powers
under the plan, and its decision should be subject to de novo
review. Lesser irregularities, like the one in this case, do
not remove the decision from abuse of discretion review, but rather
should be factored into the calculus of whether the administrator
abused its discretion.
.....We have held
that an insurer that acts as both the plan administrator and the
funding source for benefits operates under what may be termed a
structural conflict of
interest......."
ERISAclaim.com Comment:
For a healthcare provider in appealing of denied
medical benefits claims, he/she must be able to prove through the
appeal that
"an administrator utterly
fails to follow applicable procedures" in initial
denial and subsequent appeal or reviews, among other things in a
successful appeal practice. This is more important than arguing
emotionally on medical merits of the claims, which most providers
have been doing.
For more latest
federal court cases impacting your claims denials and reimbursement,
please visit
our Managed Care Court Watch at ERISAclaim.com. |
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
---------------------
"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......"
|
Tort Reform,
Fraud & Healthcare Crisis? |
|
New From Center for Justice &
Democracy:
***New Study*** Falling Claims
and Rising Premiums in the Medical Malpractice Insurance
Industry (July 7, 2005)
Appendix
News Release: New Study
Leads Attorneys General to Proclaim “No Excuse” and “A
Matter of Life and Death” (July 7, 2005)
PDF
"Joanne
Doroshow, Executive Director of the Center for Justice &
Democracy, which commissioned the report, stated, “To
put it bluntly, if you look at what the insurance
companies say about why they raise premiums, and then
look at the data in this report, thenumbers just don’t
add up. The facts are very simple: medical malpractice
payouts are down yet insurance companies have
significantly increased premiums.
This shows that
the entire campaign to limit liability for doctors over
the last several years by capping compensation to
injured patients has been a fraud, and that based on
these data, insurers must know that it has been a
fraud.”
Study Backgrounder (July 7, 2005)
PDF
|
|
ERISAclaim.com - A $1.0 Trillion
Nuclear Solution to U.S. Health-care Crisis & $44 Trillion
Budget Deficits |
-
ERISAclaim.com - New! On-site Programs for ERISA & New CMS/Medicare
Compliance
-
ERISAclaim.com: An Unique Magic for Integrated Health Systems
-
ERISAclaim.com - ERISA, Who?
-
ERISAclaim.com - ERISA 1-2-3
-
ERISAclaim.com - HSA &/Or ERISA? 95% of HSA Are Still
ERISA's!
-
ERISAclaim.com - Rx for GM $5.6 Billion Health-care Crisis with
50% Savings
-
ERISAclaim.com - CMS New Appeal Rules: "Overhaul of the Medicare
Claims Appeals System"
|
Spring Seminar
Special:
Click the above
for more info
"CCI & Bundling
& Down Coding Denials and Appeals"
The
spring special will be included in all spring seminars |
|
For
Medicare and commercial claims and all specialties:
Medicare National Correct Coding Initiative/NCCI, Medicare
fraud and abuse prevention By NCCI, and bundling and down
coding claim denials and appeals.
NCCI was developed primarily for Medicare, but used by almost
every payer nationwide. This Information is for every payer
and almost every type of claims.
I: Medicare National Correct Coding
Initiative/NCCI
This course will cover the following topics:
HCPCS
Coding
Reasons for Incorrect Coding
CCI Basics
Modifiers
The Role of CSRs in CCI
CSR Action Steps
CCI Questions
CCI Resources
II: Medicare Fraud and Abuse Prevention:
In Medicare, some of the most common forms of fraud include:
*
Unbundling or "exploding" charges,
* Billing for a service not furnished as billed; i.e.,
upcoding.
III: How to Appeal Bundling And Down
Coding Partial Claim Denials by NCCI & ERISA.
Bundling & Down Coding Claim Partial Denials Are Identified As
The Number One And The Most Important And Popular Managed Care
Hassles By AMA (PSA) Through Nationwide State Medical
Associations And Medical Specialty Societies
|
Blue Cross And Blue Shield Plans File $30 Million
Lawsuit Alleging Rent-A-Patient Fraud In Southern California
(BCBSA.com, 03/11/2005)
ERISAclaim.com - Seminar in South Dakota:
March 18-19
Alert:
We will include one-hour coverage on New Medicare Appeal Process in each of
our ERISA Seminars
Starting from April 2005
|
Last Modified on Tuesday, March 01, 2005
Implementing a New Medicare Claims
Appeals Process (PDF
45K) (3 pages)
"The law
includes a series of structural and procedural changes to the
appeals process, including:
|
Uniform appeal
procedures for both Part A and Part B claims; |
|
Reduced
decision-making time frames for most administrative appeals levels,
as well as the right to escalate a case that is not decided on time
to the next appeal level; |
|
The establishment
of new entities, Qualified Independent Contractors (QICs), to
conduct reconsiderations of claims denials made by fiscal
intermediaries, carriers, and quality improvement organizations; |
|
Use of QIC review
panels, which include medical professionals, to reconsider all cases
involving medical necessity issues; and |
|
A requirement for
appeals-specific data collection by CMS......" |
Changes to the appeals process
(PDF 646K) (511 pages)
"SUMMARY: Medicare beneficiaries and,
under certain circumstances, providers and suppliers of
health care services, can appeal adverse determinations
regarding claims for benefits under Medicare Part A and Part
B under sections 1869 and 1879 of the Social Security Act
(the Act). Section 521 of the Medicare, Medicaid, and SCHIP
Benefits Act of 2000 (BIPA) amended section 1869 of the Act
to provide for significant changes to the Medicare claims
appeal procedures. This interim final rule responds to
comments on the November 15, 2002 proposed rule regarding
changes to these appeal procedures, establishes the
implementing regulations, and explains how the new
procedures will be implemented. It also sets forth
provisions that are needed to implement the new statutory
requirements enacted in Title IX of the Medicare
Prescription Drug, Improvement, and Modernization Act of
2003 (MMA).
DATES: Effective date:
These regulations
are effective on May 1, 2005. However, in view of the
wide span of applicability of these rules and the complex,
intertwined nature of the affected appeal procedures, not
all of these provisions can be implemented simultaneously.
Please see section I.E. of the preamble for a full
description of the implementation approach....."
|
|
Unanimous US Supreme Court Ruling
In US Health Care Crisis
by Jin Zhou,
02/11/2005
© 2005,
Jin Zhou,
ERISAclaim.com
Managed-Care Nightmares?
Health-Care Crisis without True Solutions?
What Does an 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.
How
Can Anyone in USA, from Congress to General Motor to the White House,
from Industry Experts to Patient Advocates, Solve US Health Care Crisis
without Even Thinking of ERISA?
"Failure of Imagination" As a
Nation Is the Real Tragedy
ERISAclaim.com - Supreme Court Managed Care ERISA Watch
Unanimous US Supreme Court Ruling In US Health Care Crisis
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."
|
|
Health-Care 9/11 Report of 2005
Health-care WMD
by Jin Zhou,
02/05/2005
© 2005,
Jin Zhou,
ERISAclaim.com |
|
Unanimous US Supreme Court: |
Employer-Sponsored Health-Care Is Completely Governed by ERISA laws
and rules;
Aetna Health Inc. v. Davila,
06/21/04 |
|
Congressional Leaders: |
One Administration = One Voice = ERISA Self
Enforcement only, or
No Enforcement? |
|
Health-care Terrorists? |
"ERISA Advantage"
bogus plans,
"unlimited and frequent premium increases, and
the potential for rampant fraud with little, if any, regulatory
recourse" in 30 years of ERISA self enforcement. |
|
Health-care WMD (Weapons of Mass Destruction) |
"Medical
Inflation, WMD" for
"ERISA Advantage" from
ERISA Failure -
"Failure of Imagination" Again
for US Healthcare:
USA:
$1.9 Trillion, 15.7% of GDP
GM:
$5.6 Billion, $1,500 Per Car
Economists: Federal deficit a bigger risk than terrorism (USA
Today) "The survey, taken
between Feb. 28 and March 8, found U.S. businesses had three nearly
equal concerns about longer-term risks: health care, the aging
population and the federal deficit." |
|
USA
2005: |
-
Personal Bankruptcy
-
GM Chapter 11,
-
National healthcare expenditure $$1,9
trillion
-
One nation under debt
-
GAO Report: Tax
Expenditures Represent a Substantial Federal Commitment and Need to
Be Reexamined (PDF) (U.S. Government Accountability Office)
Abstract Highlights-PDF PDF
|
|
White House Rx: |
$1,000 HSA personal responsibility +AHP
with
More "ERISA advantage" for
"widespread
plan insolvencies and fraud" and
"A
Prescription For Disaster". |
|
2005 for Michael Moore? |
"John Q. ERISA
Enforcement"??? |
|
Congressional conclusion 2008:
|
"Failure of Imagination" Again, with No One's
Responsibility and Accountability. |
 
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 |
|
|
|
"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 |
"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
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
Title 29 U.S.C. § 1141 states:
"It shall be unlawful for any
person through the use of fraud, force, violence, or threat of
the use of force or violence, to restrain, coerce, intimidate,
or attempt to restrain, coerce, or intimidate any participant or
beneficiary for the purpose of interfering with or preventing
the exercise of any right to which he is or may become entitled
under the plan, this title, section 3001, or the Welfare and
Pension Plans Disclosure Act. Any person who willfully violates
this section shall be fined $10,000 or imprisoned for not more
than one year, or both. The amount of fine is governed by 18
U.S.C. § 3571. The U.S. Sentencing Guidelines address 29 U.S.C.
§ 1141 under the guidelines for "Fraud and Deceit" (U.S.S.G. §
2F1.1) or for "Extortion by Force or Threat of Injury or Serious
Damage (U.S.S.G. § 2B3.2)......"
"For example, Section 1141
would reach the use of deception directed
at misleading a welfare plan beneficiary as to the amount of
health benefits owed to the beneficiary under the terms of the
plan or at misleading a pension plan participant as to
the amount of retirement benefits to which he would become
entitled under the plan upon his retirement."
ERISA in the United States Code
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Hospital CEO's Confessed Their Biggest Headaches:
Financial Challenges from Unpaid/Denied Medical Bills in 2004 |
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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)
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CMS News on Wheelchair and
Medical Necessity |
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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:
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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.
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Developing a new
appeal-specific data
system that will allow
authorized users to
track individual
appeals in real time.
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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.
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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.
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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."
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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)
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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."
Medicare New Policy:
Medical Necessity in Emergency/Critical Care
On November 5th, CMS issued a modification to
the Medicare Integrity Manual for "Payment
for Emergency Medical Treatment and Labor Act (EMTALA) and new
policy in making emergency room medical decision terminations",
and "Instructs that for an item or service provided
by a hospital or critical access hospital pursuant to section
1867of the Social Security Act (EMTALA) on or after January 1,
2004, FIs must make determinations of whether the item or
service is reasonable and necessary on the basis of information
available to the treating physician or practitioner (including
the patient’s presenting symptoms or complaint) at the time the
item or service was ordered or furnished by the physician or
practitioner (and not only on the patient’s principal
diagnosis). The frequency with which an item or service is
provided to the patient before or after the time of the service
shall not be a consideration."
CMS Manual System
Department of Health & Human Services (DHHS)
Pub. 100-08 Medicare
Program Integrity
Centers for Medicare
& Medicaid Services (CMS) Transmittal 86 Date: NOVEMBER 5, 2005
CHANGE REQUESTS 3437
http://www.cms.hhs.gov/manuals/pm_trans/R86PI.pdf
MEDICARE BENEFICIARIES WILL SOON BE ABLE TO RESOLVE MEDICARE
APPEALS FASTER
October 18, 2004
“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.”
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CMA Rebuts Health Plan
Allegations of Unfair Physician Billing Practices
[Posted
11/11/04]
Click here to download CMA's letter to
DMHC.
MAINE UROLOGIST SENTENCED FOR HEALtTHCARE
FRAUD
(United States Department of Justice) Ocober 6, 2004
Calif. attorney general launches insurance probe
"SAN FRANCISCO,
Oct 29 (Reuters) - California's
Attorney General Bill Lockyer has
launched an investigation into
possible antitrust violations and
fraud by insurance companies and
brokers, his office said on Friday."
INSURANCE COMMISSIONER
JOHN GARAMENDI SUES BROKER AND 4 MAJOR INSURERS OVER SECRET COMMISSIONS AND
KICKBACK SCHEMES THAT NETTED “MILLIONS OF DOLLARS”
The
Complaint
and a
copy of the settlement
agreement can be accessed by clicking the
links.
Release Date: 10/21/2004
"EBSA closed 4,399 civil investigations in
FY 2004. Nearly 70% of those investigations resulted in correction
of violations under the Employee Retirement Income Security Act
(ERISA). Criminal investigations led to
the indictment of 121 individuals. In addition, EBSA received a
record 474 applications to participate in its compliance assistance
program to help employers and plan officials to voluntarily correct
specific violations of the law."
EBSA Achieves Record $3.1 Billion in Fiscal Year 2004
Results •
Press Release
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