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©2010, Jin Zhou, ERISAclaim.com

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Webinars for New Federal Appeals Laws on New EOB’s For Claims Denials, Internal And External Appeals Released On August 24, 2010 from IRS, DOL and HHS      08/26/2010  Hanover Park, IL

 

New Protections for Out-of-Network Providers Under New Federal Health Laws and Regulations – Free Webinars Announced from ERISAclaim.com     08/17/2010  Hanover Park, IL

 

Breaking News: Court Watch - ERISA Completely Pre-empts BCBSRI Overpayment PPO Claims and Fraud Claims and ERISA Limits Blue Cross' Potential Recovery

 

BCBSRI v. JAY S. KORSEN and IAN D. BARLOW

 

UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF RHODE ISLAND

10/27/10

[page 16-17 of 19]

 

"In the case before the bench, Blue Cross, as a fiduciary, can make its claim under § 502(a) (3), which permits a participant, beneficiary or fiduciary of an ERISA plan to bring a civil action "(A) to enjoin any act or practice which violates any provision of this subchapter or the terms of the plan, or (B) to obtain other appropriate equitable relief ... " 29 U.S.C. §1132(a) (3). The Court holds further that there is no independent legal duty controlling Defendants' conduct herein; because, while the Provider Agreements do impose duties on Defendants, these duties are not independent of the terms of the ERISA plans. Consequently, the Court holds that Blue Cross' Count I for breach of contract, alleging that Defendants breached the Provider Agreements by submitting claims using improper CPT codes and submitting claims for services that were inappropriate or not medically necessary, and Count II for fraud are completely preempted by ERISA. The Court converts these claims to a federal ERISA § 502 (a) (3) claim.

As part of Count I, Blue Cross also alleges that Defendant Korsen breached the Provider Agreement by terminating the Provider Agreement without providing 60 days notice. This portion of the state-law breach of contract claim is not subject to ERISA's complete preemption and thus is unaffected by the Court's decision today. Though the Court's ruling limits Blue Cross' potential recovery, this holding is consistent with the legislative aims identified by the Supreme Court in Davila: "The limited remedies available under ERISA are an inherent part of the 'careful balancing' between ensuring fair and prompt enforcement of rights under a plan and the encouragement of the creation of such plans." 542 U.S. at 215 (quoting pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41, 55 (1987). Moreover, the Congressional objectives of consistency in regulation and uniform administration of ERISA plans are met.

Congress' intent to make the ERISA civil enforcement mechanism exclusive would be undermined if state causes of action that supplement the ERISA § 502(a) remedies were permitted, even if the elements of the state cause of action did not precisely duplicate the elements of an ERISA claim."

 

Court Watch: UnitedHealthcare Sued In ERISA Class Action Over Its Overpayment Recoupment Practice

 

© Jin Zhou, President, ERISAcalim.com

08/06/2010

"Hanover Park, IL (ERISAclaim.com) August 06, 2010 - UNITED HEALTHCARE was sued in ERISA class action counterclaims on July 21, 2010 in United States District Court, Southern District of New York, for the alleged ERISA violations in its overpayment practice by patients and providers.

 

This is the third provider ERISA class action lawsuit against Insurers since Aetna was sued in last July and 21 BCBS Entities in last Sept in federal courts over payer’s overpayment recoupment practice, after a federal court ruled in Chicago on BCBS case allowing provider’s ERISA class action claim to proceed, said Dr. Zhou.

" (Read more......)

 

ERISAclaim.com - Health Reform for Out-Of-Network Providers:

Receiving Insurance Checks Directly? – CD Books & Seminars on Why & How  04-05-2010

 

Federal Court Ruling On Provider Class Action

MD Edgar Borrero v. United Healthcare of New York

 

http://www.ca11.uscourts.gov/opinions/ops/200815264.pdf

 

IN THE UNITED STATES COURT OF APPEALS

FOR THE ELEVENTH CIRCUIT

 

<<http://www.ca11.uscourts.gov/opinions/ops/200815264.pdf>>

 

July 6, 2010

“Consistent with Connecticut State Dental, at least some of the claims pursued by the Appellants implicate legal duties dependent on the interpretation of an ERISA plan. These claims—about wrongfully denied benefits based on determinations of medical necessity—relate directly to the coverage afforded by the ERISA plans. Many of the other allegations in the complaint, for practices like downcoding and bundling, are based on independent provider-insurer contracts and do not implicate ERISA. But, because at least some of the allegations are dependent on ERISA, those claims are completely preempted and federal question jurisdiction exists. Because Appellants’ claims are completely preempted by ERISA, a federal court has subject matter jurisdiction over Appellants’ suit.” (Emphasis added)

 

03/23/2010

Breaking News

 

President Obama Signed Into the Law the Healthcare Legislation to Revamp Healthcare Reimbursement Laws for All Group Health Plans and Health Care Providers

 

The Final Health Reform Bill Has Been Signed By President Obama Into The Law Of The Land For More Than 95% Americans, As The Most Significant Changes Since Medicare Was Created 45 Years Ago. What Does Obama Healthcare Law Mean To Healthcare Providers And Health Plans? The New Federal Reimbursement Laws Protect Health Care Providers with ERISA Internal And External Appeals, Extended Disclosure And Appeal Rights, New Federal UCR Fee Centers And New Federal Simplified, Uniform Standards For Claim Processing And Appeals. The New Federal Reimbursement Laws Will Eventually Eliminate Most Managed care Abuses

 

 

 

 

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

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."

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

 

 

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

 

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 


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

 

Pomerantz Files Class Action Against Blue Cross Blue Shield Association

 

Sept. 10, 2009

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

For a copy of the BCBSA Complaint, click here

 

 

 

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.

 

 

 


Healthcare Industry Taskforce Banner

 

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 settles with NY over bill database
The Associated Press
ALBANY, NY (AP) — Under a settlement with New York, UnitedHealth Group Inc. will overhaul a health insurance industry pricing database to make sure patients ...
UnitedHealth settles NY AG reimbursement probe Reuters
Report: UnitedHealth agrees to settle NY probe Bizjournals.com
Health insurer accused of overcharging millions MSNBC
Connecticut Post - Pioneer Press
all 153 news articles »  UNH

 

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.”

 

 

$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

 

Insurer UnitedHealth to pay $350M for settlement
Minneapolis Star Tribune, MN - Jan 15, 2009
Thursday's settlement comes two days after another a $50 million settlement of a probe by New York Attorney General Andrew Cuomo into whether UnitedHealth ...
UnitedHealth Group settles class-action suit over database, Ingenix Chicago Tribune
UnitedHealth agrees to $350 million settlement with AMA ModernHealthcare.com
Insurer UnitedHealth to pay $350M for settlement The Associated Press
Crain's New York Business - MarketWatch (press release)
all 630 news articles »  UNH - OTC:CMTX

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

 

 

Opinions Forms Rules Courts Programs Careers Reference Search Site
Welcome to the California Courts Web site


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 ...

Balance Billing Nixed by California Supreme Court
Wall Street Journal Blogs, NY - Jan 9, 2009
The case was all about “balance billing” — a perpetual bone of contention in the health care world, where doctors and hospitals bill patients for a balance ...
State Supreme Court bans ER 'balance billing' Bizjournals.com
Calif. high court bans balance billing ModernHealthcare.com
Top California Court Disallows 'Balance Billing' for ER Treatment MedPage Today
FierceHealthcare - SmartBrief
all 125 news articles »

 

© JIN ZHOU, President,

ERISAclaim.com

Jan. 13, 2009

 

 

 

Medicare Overpayment Appeals

 

"Dr.Joe (Zhou), the RAC Invalidator"©

 

"2009, Healthcare $1 Trillion  Bubble"

You Must Pay to Bailout

You ARE the Bailout Plan, not Congress

 

 

 

 

  1. Dr. Jin Zhou will be speaking at World Research Group's "Summit on Medicare Advantage Reimbursement for Hospitals"

  2. E-mail Your Questions to ERISAclaim@aol.com

 

2007 Claim Denial & Overpayment Dispute

ERISA Appeal Seminar

 

Our New Seminar Schedules for 2007 & 2008

are Published on Seminar Page

 

$299 - $600

Call: 630-736-2974

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

E-mail Your Questions to ERISAclaim@aol.com

 

How to Sign up?

 

               Our new 2007 ERISA Seminars can be enrolled by

 

1. Calling 630-736-2974

 

2. Download, fax a completed Registration Form to 630-736-1439

 

3. Online Secured registration.

 

Maximizing Healthcare Claim Reimbursement

Problem Oriented Appeals under ERISA

 

 

Dr. Jin Zhou Will Speak at This 2007 National Conference



 

World Research Group has also organized two in-depth workshops conducted by the industry’s thought leaders that will drill down into the solutions you need to prevent, reduce and overturn denials. Register for both to maximize your on-site learning experience.

 

Don’t Miss these Must-Attend, In-Depth Workshops!

links to registration: http://worldrg.com/showConference.cfm?confcode=HW765
 

For a brochure, click here 

 
4th Annual Optimizing Managed Care Contracting for Hospitals
September 19 - 20, 2007
Chicago, IL
Register   •  
Download a Brochure
 

 

 

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

 

 

Vacca et al v. Trinitas Hospital

Nov. 14, 2006

UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF NEW YORK

 

ERISA Does Not Authorize or Provide Remedy for
Plan's Overpayment Recoupment Actions
Against Healthcare Provider

 

We provide healthcare providers with in-house consulting and turn-keys programs
if you have big claims or a lot of  overpayment troubles

 

Call: 630-736-2974

Email: ERISAclaim@aol.com

www.ERISAclaim.com

 

Comments from other legal websites

Health Plan Lawsuit Watch (aishealth.com)

Health Care Managed Care Lawsuit Watch (Crowell & Moring LLP)

Health Plan Law - ERISA Group Health Plan Administration » 2006

"Plan’s Suit Against Hospital For Overpayment Dismissed Based Upon Knudson Analysis"

 



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......"

 

A Consumer Guide to Handling Disputes with Your Employer or Private Health Plan -- 2005 Update (Kaiser Family Foundation)

 

What You Need to Know About Your Employer-Sponsored Coverage

"If you are enrolled in an employer-sponsored health plan, your right to appeal disagreements about benefits through your plan’s internal appeals process is determined by federal law (the Employee Retirement Income Security Act, or ERISA) and a federal ERISA regulation that became effective January 1, 2003." 

Full Report (pdf)

 

USNews.com: Health: In Brief: Public Health: Winning fights with your HMO (8/12/05)

 

 

 

 

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

 

 

 

Breaking News:  Employer Must Reimburse Medicare

for Over Payments under MSP

 

Telecare Corp. v. Leavitt

(Fed. Cir. 2005)

More on Medicare $ ERISA Page.

 

 

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

 
ERISA CD Book: $450 Medicare CD Book: $250
Holidays' Special -  ERISA CD & Medicare CD: $560

[More info on CD Books]       [Order CD Book]

 

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

 

 
 New CMS Transmittals

NEW CMS HIPAA Forms

SIZE FILE Adobe PDF Icon Sorted in Decreasing Order  COMM DATE MANUAL SUBJECT IMPL DATE CR NUM
254 kb R20GI 4/29/2005 PUB 100-01 "Medicare Authorization to Disclose Personal Health Information" form and "Information to Help You Fill Out the Medicare Authorization to Disclose Personal Health Information Form" 5/31/2005 3485

 

 

 

Aetna, CIGNA CEOs Got 8-Figure Pay Packages (Connecticut Business, March 22, 2005)

"Dr. John W. Rowe, Aetna's chairman and CEO, took in $22.2 million in 2004, including $18.2 million of value from exercising stock options. He also got 250,000 new stock options with a potential value of $6.1 million."

 

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....."

 

New U.S. Treasury -HSA FAQs Has Grown from 58 to 85,
Under Eight Topic Headings
(Links to U.S. Treasury)

U.S. Department of the Treasury LogoOffice of Public Affairs
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

 

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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."

 

 

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)

 

 

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:
  1. Personal Bankruptcy
  2. GM Chapter 11,
  3. National healthcare expenditure $$1,9 trillion
  4. One nation under debt
  5. 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.
 

 

 

New York State SealPress Releases
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
  •  

     

    New York State Seal

    New York State, Insurance Department

    ISSUED 4/13/2004

    FOR IMMEDIATE RELEASE

    Health Net To Refund $4.99 Million To Policyholders And Re-Evaluate Some Healthcare Claims (The full report, pdf)          

    Also Paid $500,000 Fine And Instituted Remedial Actions Under Separate Department Action      

     

    Press Releases

    Department of Law
    120 Broadway
    New York, NY 10271

    Department of Law
    The State Capitol
    Albany, NY 12224

     

    For More Information:
    (212) 416-8060

    For Immediate Release 
    March 30, 2004

    HEALTH PLANS FAIL TO DISCLOSE REQUIRED COVERAGE INFORMATION

    New Report Shows HMOs Do Not Adequately Comply with State Law

     

    ATTENTION RADIO NEWSROOMS:
    AN AUDIO CUT IS AVAILABLE BY CONTACTING THE ATTORNEY GENERAL'S 24 HOUR TOLL-FREE NEWS LINE AT (877) 345-3466, CHOICE #1.

     

    Press Release

    Survey Report - (HTML Version | PDF Version)

     

    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
     
    "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

     

    1. Rising Health care Costs Have Many Implications (Direct)

    2. Rising Healthcare Costs Have Many Implications (Indirect)

     
     
     
    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  Sort Descending (Z to A)Sort Ascending (A to Z) 
    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?

     

     

    DOJ: Criminal Resource Manual 2432 Coercive or Fraudulent Interference with ERISA Rights -- 29 U.S.C. 1141

    2432 Coercive or Fraudulent Interference with ERISA Rights -- 29 U.S.C. 1141

    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

    ERISA 510 29 USC 1140 Interference with protected rights.
    ERISA 511 29 USC 1141 Coercive interference.

     

    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)

     

    Department of Justice Seal Department of Justice

    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)

     

     

     

     

    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

    US Map

     

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

     

     

    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.

     

    U.S. Labor Secretary Elaine L. Chao Announces Stronger Retirement, Health Benefit Security for American Workers - 121% Increase in Monetary Results Shows “Commitment to Protect Hard-Earned Benefits” 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

     

     

    INVESTIGATION REVEALS WIDESPREAD CORRUPTION IN INSURANCE INDUSTRY

    Press Releases

     
    Department of Law
    120 Broadway
    New York, NY 10271
     
    Department of Law
    The State Capitol
    Albany, NY 12224
     
     
    For More Information:
    (212) 416-8060
    For Immediate Release 
    October 14, 2004

    Leading Brokerage Firm Sued for Fraud and Antitrust Violations; Insurance Company Executives Plead Guilty; Major Insurance Firms Implicated

    "Attorney General Eliot Spitzer today sued the nation's leading insurance brokerage firm, alleging that it steered unsuspecting clients to insurers with whom it had lucrative payoff agreements, and that the firm solicited rigged bids for insurance contracts."

     

    Attachments:

     

    11/12/04 Life, Disability Broker Charged with Fraud, Antitrust Violations
    Anti-Competitive Actions Led to Higher Insurance Premiums for Employees

     

    11/18/04 Spitzer and Serio Announce Settlement with Nation's Largest Disability Insurer
    Multi-state settlement with UnumProvident imposes sweeping reforms that will protect disabled workers nationwide

     

    ERISAclaim.com

    Happy
Birthday

    Sept. 2,
1974

    30th
Birthday

     

    Happy or Sad 30th Birthday To ERISA?

    (Copyright © 2004 by Jin Zhou,  ERISAclaim.com)

    Sept. 2, 2004

    On Sept. 2, 1974, exactly 30 years ago today, ERISA, The Employee Retirement Income Security Act, was signed into law by President Gerald R. Ford. The congressional intent in enacting ERISA was to protect employees in pension and welfare plans, to provide uniform federal protections in response to the failure of the Studebaker Co. in December 1963, with thousands of long-service employees cheated out off their promised pensions, and to preempt any state laws when the employees pension and welfare benefits were threatened. 30 years later, ERISA Failure in its compliance and enforcement left thousands of retirees without medical benefits, and resulted in a skyrocketing national healthcare expenditure explosion with 45 million uninsured and a possible national pension bailout.

    ERISA Failure Syndrome

    U.S. Healthcare Crisis Trilogy

     

    Jin Zhou Identifies "ERISA Failure" That Killed U.S. Healthcare

    "Failure of Imagination" Again?

     

     

     

     

    ERISA Celebrates 30th Anniversary As Trouble Brews For the Pension Insurance Program (Spencer Benefits Reports)

    Excerpt: "The seed for ERISA was planted with the failure of the Studebaker Company in December 1963, leaving thousands of long-service employees without their promised pensions."

     

     

     

    Rx-1  $$$$$$$$

    "LONG LIVE HMO"

    $$$$$$$$$  Rx-2

     

    Life and Health Insurers' Earn $26 Billion in First Nine Months of 2004, According to Weiss Ratings (Business Wire (press release), CA - Mar 15, 2005)

     

    Weiss Ratings: HMO & Health Insurance News Releases

    Release Date
    2/7/2005     Higher Co-Pays for Drugs and Doctors Cited as
    Most Significant Change to Health Insurance Coverage
    2/7/2005     50% of HMOs Financially Strong as Profitability Continues
    12/8/2004     HMO Profits Increase 33% in First Quarter 2004
    8/30/2004     HMOs Earn $10.2 Billion in 2003, Nearly Doubling Profits
    5/3/2004     HMO Profits Skyrocket to $6.7 Billion in First Nine Months of 2003
    3/2/2004     HMO Profits Surge 73% in Second Quarter 2003
    1/20/2004     HMO Profits Jump 60% in First Quarter 2003

     

    1. GM Credit Rating Cut Again (TheCarConnection.com)

      "In addition, health-care costs in the United States continue to increase at an excessive rate and are a growing burden on GM's financial results. "These continuing large increases in healthcare costs put GM, and many other U.S. businesses, at a significant disadvantage," said Wagoner."

    2. GM's Spinning Wheels (Motley Fool)

    3. Ford Posts Profit on Credit, Autos Lose (reuters.com)

    4. Ford makes more from selling loans than making cars (telegraph.co.uk)

     

     

    Post Supreme Court Davila Scoop:

    ERISA Pre-emption of State Laws in Healthcare

     

    State of Connecticut v. Health Net, Inc.,

    11th Cir. 09/10/2004

    State Can NOT Enforce ERISA, Publicly or Privately
    (
    ERISAclaim.com - Managed Care Court Watch)

     

    Hawaiian Court Reverses Lower Court Ruling on ERISA Preemption of State Law on External Review

    (The Supreme Court of the State of Hawaii)

    Excerpt: "The Hawaiian Supreme Court ruled November 18, 2004, that a state law that gives Hawaii's insurance commissioner authority to conduct external reviews of health insurance plan decisions is 'impliedly' preempted by the Employee Retirement Income Security Act (ERISA)."

     

    Medicare & ERISA, Am I in Trouble Again?

    (2X$+IR$+$5K) +$183 million

     

    Medicare Secondary Payer: Improvements Needed to Enhance Debt, GAO Says (U.S. Government Accountability Office)

    32 pages. Excerpt: "Last year, employer-sponsored group health plans ... were responsible for most of the nearly $183 million in outstanding Medicare secondary payer (MSP) debt. MSP debts arise when Medicare inadvertently pays for services that are subsequently determined to be the financial responsibility of another. The Centers for Medicare & Medicaid Services ... administers Medicare with the assistance of about 50 contractors that, as part of their duties, are required to recover MSP debt."

     

    Telecare Corp. v. Leavitt

    (Fed. Cir. 2005)

     

    ERISAclaim.com: "employer-sponsored group health plans" = "ERISA-regulated benefit plans", both self-insured and fully-insured (through purchase of insurance) health plans, (ERISA - Title 29, Chapter 18.  Sec. 1002.)

     

    Inquiry on Medicare Finds Improper Limits on Choices of Health Care Providers (The New York Times; one-time registration required)

    Excerpt: "Federal investigators said Monday that the Bush administration had improperly allowed some private health plans to limit Medicare patients' choice of health care providers, including doctors, nursing homes and home care agencies."

    Medicare Demonstration PPOs: Financial and Other Advantages for Plans, Few Advantages for Beneficiaries GAO-04-960, September 27, 2004

    Abstract    Highlights-PDF    PDF 

     

     

    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)

     

     

    California SB 1569/Knox-Keene Act, "Allowing Physicians to Sue Health Plans for Fair Payment",
    Will be Preempted by ERISA

    (Copyright © 2004 by Jin Zhou,  ERISAclaim.com)

    08/30/2004

    "The article is to explore whether the Employee Retirement Income Security Act of 1974 (ERISA), 88 Stat. 832, 29 U. S. C. §1001 et seq., pre-empts California "SB 1569"/Knox-Keene Act to the extent it applies to ERISA plans. I believe it does, in accordance with the Supreme Court ruling for both Egelhoff v. Egelhoff  and Aetna Health Inc. v. Davila."

    DOL Advisory Opinion 96-06A

    "This is in response to your request for an advisory opinion concerning the applicability of Title I of the Employee Retirement Income Security Act of 1974 (ERISA). Specifically, you ask whether California's Knox-Keene Health Care Service Plan Act of 1975, California Health & Safety Code Section 1340 et seq. (Knox-Keene), would be preempted by section 514(a) of Title I of ERISA if it were applied to prohibit a welfare benefit plan from providing participants with incentives to influence their choices among alternative benefits offered under the plan."

     

    Business Insurance - Health cost moderation boosts insurer profits: Best (Jan. 17, 2005)

     

    "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. "

    HMOs Earn $10.2 Billion in 2003, Nearly Doubling Profits, According to Weiss Ratings;
    Blue Cross Blue Shield Plans Report 63% Jump in Earnings
    (BUSINESS WIRE)--Aug. 30, 2004

     

     

     

    California Nurses Association: New Study Documents High Markups on Hospital Charges

     

     

     

    Class-Action Status Is Upheld for Doctors Suing Insurers (The New York Times)

    "An appeals court upheld class-action status yesterday for a lawsuit brought on behalf of at least 600,000 doctors contending that six of the nation's largest health insurers regularly reduce payments for medical services."

    Eleventh Circuit Court of Appeals Affirms Class Certification for RICO Lawsuit Filed by the Nation’s Doctors Against Leading HMOs (hmocrisis.com)

    "Plaintiff’s Lead Counsel Archie Lamb: Largest Physician Led Class Certification in Federal Court History Has Now Been Affirmed

     

    Wednesday September 1, 2004:  The Eleventh Circuit Court of Appeals issued a sweeping decision today affirming class action certification in the landmark RICO case filed to combat widespread and chronic abuses by some of the nation’s largest for profit HMOs." 

     

     

     

    ERISA Failure Syndrome

    U.S. Healthcare Crisis Trilogy

    (Copyright © 2004 by Jin Zhou,  ERISAclaim.com)

     

    ERISA
    Medical Killing

    ERISA
    Medical Inflation

    ERISA
    Insurance Robbery
    "Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance

    Read Making a Killing

    ?

     

    ?

    Bar graph showing trends in hospital charges and revenues in California from 1995-2002

    ?

     

    ?

    GAO-04-312

    ?
     

    ?

    American Job ExportING!

    Mass layoffs up in January 2004

    Weirton Steel cancels 10,000

    GM: $67.5 billion in 2003

    One Nation under Debt: U..S. economy threatened by aging of America

     

    Healthcare Disaster at Fault Verdict Index:

    U.S. Government 30%

    U.S. Employers & Insurers 30%

    Healthcare Providers 30%

    Consumers 10%

    (ERISA Failure + Managed-Care) Destroyed US Healthcare
    (ERISA Failure + Managed-Care + HSA) Invite US Federal Budget Deficit & Social Security Disasters = 100X 9/11 Attacks

     

    GAO: Current and Emerging Fiscal and Retirement Security Challenges, American Benefits Council/MetLife Conference, Washington, DC, on January 14, 2005

    1. Rising Health care Costs Have Many Implications (Direct)

    2. Rising Healthcare Costs Have Many Implications (Indirect)

     

    Rx-1  $$$$$$$$$ERISA"Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance
$$$$$$$$$$  Rx-2

     

    "Failure of Imagination" & Solutions?

    THE 9/11 COMMISSION REPORT (pdf)


    Healthcare Fahrenheit 9/11 Pre-Commission Report

     

     

     

     

     

    Jun 30, 04  Application & Proposed Order to Hear Motion to Include Parties to Thomas & Solomon Actions Within the Scope of Stipulated Protective Orders on Shortened Time

     

    "CHICAGO — Blue Cross and Blue Shield Association (BCBSA) today announced total enrollment in 41 independent Blue Plans across the country reached 88.8 million members at the end of 2003, up from 85.3 million at the end of 2002.  This marks the 9th consecutive year that the Blue Cross and Blue Shield System has recorded enrollment growth."

    CLASS ACTION LAWSUITS BY UNINSURED PATIENTS BROUGHT AGAINST SIX MORE NONPROFIT HOSPITAL SYSTEMS AROUND THE COUNTRY - 07/09/04 (hospitalpricegouging.org)

     

    Lawsuit Filed Against National “For-Profit” Hospital Groups To Protect Uninsured Patients From Hospital Price Gouging And Unconscionable Billing Practices - August 5, 2004 (hospitalpricegouging.org)

     

    Class action accuses Sutter of overcharging the uninsured Article from the Sacramento Business Journal (hospitalpricegouging.org)

    Subcommittee on Oversight and Investigations, House Energy and Commerce Committee “A Review of Hospital Billing and Collection Practices”, June 24, 2004

    Health-care crisis and the failures encountered nationwide as alleged in class-action lawsuits have set off alarms and High alert for ERISA failure & crisis.

     

    "Failure of Imagination" Again?

    "John Q.
    ERISA
    Enforcement"

     

    "Class Actions" v. "New Strike Force"

     

    HMOs Earn $10.2 Billion in 2003, Nearly Doubling Profits, According to Weiss Ratings; Blue Cross Blue Shield Plans Report 63% Jump in Earnings (BUSINESS WIRE)--Aug. 30, 2004

    Medicare | Fraud, Abuse in Medicare and Medicaid Could Exceed Government Tracking Figures - Kaisernetwork.org

    "In a statement, Sen. Larry Craig (R-Idaho), Chair of the Senate Special Committee on Aging, said, "In these tight budgetary times, it is important that every dollar that the federal government spends be well spent for its intended purpose ... But as we go after waste, fraud and abuse within Medicare, we need to make sure that we do not overreact."

    Health care now prime target of federal False Claims Act (AM News)

    "No place for fraud"

    "There is no place for fraud in the practice of medicine," said AMA President-elect John C. Nelson, MD. "However, it is important that as the government investigates health care fraud, there is recognition, and separation, of inadvertent errors by health care professionals from real fraud."

     

    82M U.S. Residents Uninsured at Some Point Over Last Two Years, Study Says - Kaisernetwork.org

     

    EBRI Frequently Asked Questions About Benefits

     

    One in Three: Non-Elderly Americans Without Health Insurance, 2002-2003 (Families USA)

     

    Doctored Books (motherjones.com)

    "Richard Scruggs sued Big Tobacco and won. Now, he's taking on some of the nation's biggest non-profit hospital chains on behalf of the uninsured."

    Nonprofit Hospitals Said to Overcharge Uninsured (The New York Times)

    "A group of plaintiffs' lawyers filed civil lawsuits against more than a dozen nonprofit hospitals across the country yesterday, contending that the hospitals violated their obligation as charities by overcharging people without insurance and then hounding them for the money."

    Health Care Continuation Coverage; Final Rule [Rules and Regulations] [05/26/2004] | [PDF Version]| [Notices] | [Press Release]

     

    DOL Health Benefits Education Campaign [New  Seminars: IL, NY, KY]

    DOL Launches National Education Campaign "Getting It Right-Know Your Fiduciary Responsibilities"

     

    Press Release  EBSA News Release: [05/18/2004]

    Seminars are scheduled for Florida, Ohio, Massachusetts and Arizona, beginning in June 2004. The program will emphasize the obligation of plan sponsors and other fiduciaries to:

    • Understand the terms of their plans;

    • Select and monitor service providers carefully;

    • Make timely contributions to fund benefits;

    • Avoid prohibited transactions; and

    • Make timely disclosures to workers and their beneficiaries and reports to the government.

    Publications

    Meeting Your Fiduciary Responsibilities

    Understanding Retirement Plan Fees And Expenses

    Selecting An Auditor For Your Employee Benefit Plan

    Reporting and Disclosure Guide for Employee Benefit Plans

     

    NEW Utah State law Mandates ERISA Claim Regulation
    (
    Copyright © 2004 by Jin Zhou,  ERISAclaim.com)

    Did you know that, since enacted on May 17, 2002, a NEW Utah State law, UT Admin Code R590-203. Health Grievance Review Process and Disability Claims., has mandated every health insurer and HMO conducting business in the State of Utah to comply with ERISA claim regulation, regardless if the plan is actually an ERISA plan?

     

    This is the first state law for health insurance and manage care that mandates and clones ERISA claim regulation at state-level. More and more states are expected to follow.

     

    UT Admin Code R590-203. Health Grievance Review Process and Disability Claims.

    "R590-203-2. Purpose.


    The purpose of this rule is to ensure that health insurer's grievance review procedures for individual and employer health benefit plans comply with the Department of Labor, Pension and Welfare Benefits Administration Rules and Regulations for Administration and Enforcement: Claims Procedure, 29 CFR 2560.503-1, Utah Code Sections 31A-4-116 and 31A-22-629."

     

      (Bulletin) (Utah Code Section 31A-22-629)

     

    PROPOSED RULE CHANGE- R590-203,  Health Grievance Review Process and Disability Claims

    This rule is being amended.  A hearing has been scheduled for 12-2-04
        at 1pm in Room 3112 of the State Office Building.  Written comments
        will be accepted until 12-15-04. 

    R590-232,  Authorization for a Health Maintenance Organization to Provide Services as Third Party Administrator of Health Care Benefits

     

    Who Can Be a Medical Reviewer under ERISA?
    (Copyright © 2004 by Jin Zhou,  ERISAclaim.com)


    U.S. SUPREME COURT
    Docket for 03-83
     

    ORAL ARGUMENT TRANSCRIPTS (page 46 0f 49)

      02-1845. Aetna Health Inc. v. Davila

    03/23/04

    "QUESTION: Mr. Estrada, you can address what you would like but there are three points that have come up during the Respondent's presentation that I'd be interested with a response to.

     

    Number one, is it true that the people who make the decisions for your client must be medical doctors in Texas?

     

    MR. ESTRADA: Well it is true by virtue of DOL regulations which provide that no claim may be turned down without input from a medical professional in the relevant area"

    New Federal Claim Regulation (Final Rule)

    1. "Plans must consult with appropriate health care professionals in deciding appealed claims involving medical judgment." [70268-70269, CFR § 2560.503-1(h)(3)(iii)]

    2. "The term `health care professional' means a physician or other health care professional licensed, accredited, or certified to perform specified health services consistent with State law." [page 70271 CFR § 2560.503-1(m)(7)]  

     

    • "medical doctors in Texas" = MD licensed to practice medicine in Texas for a Texas ERISA case;

    • "a medical professional in the relevant area" = relevant area of state laws in license jurisdiction, scope of practice and relevant local standard of care;

    • "licensed" = licensed by the State Government/licensing board;

    • "to perform" = to practice medicine or health care services in the State;

    • "specified health services" = medical procedures or services being reviewed or denied, instead of file review or insurance coverage reviews services;

    • "consistent with State law" = consistent with State laws where  the health care professional is legally licensed to practice medicine or health care services with respect to state jurisdictions,  scope of license and state local medical standard of care.

     

    "The term `health care professional' means, in layman term,  a physician or other health care professional who is at least licensed in your state (and more, board certified too) to practice the specified/specific health services being reviewed or denied of your claims, consistent with your state law jurisdiction, scope of practice and local medical standard of care. Someone who is not licensed to practice the same health care services specified/denied in your claims is not qualified as an "appropriate health care professionals" as defined under ERISA § 2560.503-1(m)(7).

     

    Someone who is not licensed in your state to practice "specified health services" but who is merely registered under state or other means (URAC, IME, SSD or Peer Reviews) to do Utilization Reviews (UR) is not qualified as an "appropriate health care professionals" as defined under ERISA § 2560.503-1(m)(7).

     

        U.S. Supreme Court visited ERISAclaim.com in regard to ERISA § 2560.503-1(h) at 11:57:03 AM on Friday, November 21, 2003 for this No. one point. Click here for more coverage of Supreme Court Visiting at ERISAClaim.com.

     

    The Root of U. S. Healthcare Crisis

    Jin Zhou, ERISAclaim.com

    The Hearing at Senate Committee on Finance on 3-3-04, [View Video "Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance
or Transcript (PDF) (KaiserNetwork.org)]  revealed the mechanism, nature and extent of ERISA failure and nonenforcement as the reasons for "Growth in Bogus Health Insurance Plans Targeting Desperate Small Business Owners", as being concluded as "No the results are not good. It’s a tragedy." by Ann Combs, assistant secretary of DOL. The mechanism, nature and extent of ERISA failure and nonenforcement as presented at the Hearing are universally true and applicable to all health care claim denials and delays in managed care environment from all employer sponsored health plans as the root of U. S. healthcare crisis.

     

    This is a 911 call on "healthcare 9/11 disaster"!

    THE 9/11 COMMISSION REPORT (pdf)

     

     

    Fraud Health Care Cards

    "New Strike Force"

    Medical Fraud Every Day?

    Appeal or Re-Bill After Denial?

    You Must APPEAL

    No Re-Billing!!!

    Claim Appeal or Sentencing Appeal?

    Your Choice

    Maximal Reimbursement
    through ERISA Appeal &

    Fraud Prevention and Compliance

     

    Aetna:  Leading the Fight Against Health Care Fraud [PDF] View as HTML

    "Thanks to this highly collaborative relationship, we know how to identify fraud because we know what to look for.

     

    Medical Fraud

    1. Unusual provider billing practices.

    2. Discrepancy between the submitted diagnosis and the treatment.

    3. Diagnoses or treatments that are outside the practitioner’s scope of practice.

    4. Claims that are resubmitted with coding changes to gain benefits.

    5. Alterations on claim submissions.

    6. Pressure for quick claim payment."

    Payments Go Under a Microscope (washingtonpost.com) January 12, 2004

    "MAMSI and CareFirst recoup overpayments to doctors by making deductions from future reimbursements. Doctors can appeal insurers' decisions. But, in the end, they usually pay up, doctors and insurers agree."

    Employers Audit Workers' Health Claims (Wall Street Journal via SFGate.com)

    Excerpt: "Looking to bring down soaring health-care costs anywhere they can, more employers are scouring their health plans for fraud, abuse and simple mistakes by employees or administrators.

    .......The number of requests for such audits jumped 50 percent last year, Mr. Farley estimates."

    Blue Cross and Blue Shield Association Announces New Strike Force to Protect American Consumers from Fraud and Fight Rising Costs (U.S. Newswire, 4/19/2004)

    "DETROIT, April 19 /U.S. Newswire/ -- The Blue Cross and Blue Shield Association (BCBSA) today announced a new Anti-Fraud Strike Force comprised of top Blue Plan investigators that will work with the Federal Bureau of Investigation (FBI) and other national, state and local law enforcement agencies to fight major insurance fraud schemes that rob consumers of millions of dollars annually. BCBSA President and CEO Scott P. Serota announced the new initiative in a speech to the Detroit Economic Club."

     

    "The National Health Care Anti-Fraud Association (NHCAA) estimates that healthcare fraud costs American consumers more than $50 billion annually. Billing for services not rendered and misrepresentation of provided services are the most common types of healthcare fraud."

    Task force targets health care cheats - (04/20/04, The Detroit News) 

     

     

    Clinton Township Firm Convicted of Overbilling (Macomb Daily)

    "The case is somewhat unusual in that a corporation was named as a criminal defendant in the case, but Kaiser said that is not unheard of since corporate law can make a firm liable for criminal wrongdoing, and its principal office holders in return are responsible for any judgments or punishments the courts impose.

    David Griem, the defense attorney for Emergency Management who was also named the principal to enter a guilty plea on its behalf, also could not be reached for comment after the sentencing hearing. In court, however, he turned over a check to the Blue Cross insurance company officials in attendance and said the company would pay the $5,000 court costs on time as well."

    Medicare | Fraud, Abuse in Medicare and Medicaid Could Exceed Government Tracking Figures - Kaisernetwork.org

     

    "In a statement, Sen. Larry Craig (R-Idaho), Chair of the Senate Special Committee on Aging, said, "In these tight budgetary times, it is important that every dollar that the federal government spends be well spent for its intended purpose ... But as we go after waste, fraud and abuse within Medicare, we need to make sure that we do not overreact."

    Health care now prime target of federal False Claims Act (AM News)

    "No place for fraud"

    "There is no place for fraud in the practice of medicine," said AMA President-elect John C. Nelson, MD. "However, it is important that as the government investigates health care fraud, there is recognition, and separation, of inadvertent errors by health care professionals from real fraud."

    Insurers make only small dent in medical-claims fraud (cbs.marketwatch.com)

    "Byron Hollis, national antifraud director for the association, said the association plans to escalate its fight against fraud and noted that the group increased its investigative staff to 500 in 2003, up 30 percent from fewer than 400 the year before."

     

    "He noted that the association's insurers still might recover more of last year's fraudulent claim payments because some of the cases have yet to go to court."

    U.S. Department of Justice Seal

    Health Care Fraud Report

    Fiscal Year 1998

    Link to Site Map

    USDOJ: Deputy Attorney General: Publications and Documents - - Health Care Fraud Report Fiscal Year 1998

     

    "On June 4, 1998, in the District of Maryland, Levindale Geriatric Hospital paid $800,000 to resolve allegations it violated the FCA by recoding and resubmitting denied charges for room and board. After the claims for room and board were denied by the Medicare Part A program, Levindale recoded the claims as supplies, laboratory work and other services, and submitted the claims for payment. In addition to paying a substantial penalty under the FCA, Levindale entered into a compliance agreement with HHS-OIG"

     

    New Study: ER Denials?
    Medical or ERISA Appeals? Appeals!

    (Copyright © 2004 by Jin Zhou,  ERISAclaim.com)

    "There are two take-home messages for health professionals," Hall said. "One, insurers much less often question the appropriateness of emergency services"  = not about Medical necessity; 

     

    "and two, if insurers initially deny coverage for emergency care, providers or patients should appeal."  = ERISA Appeals

     

    "However, some compliance problems did emerge. Some insurers, Hall told Reuters Health, initially deny ED claims and then "quickly reverse" their decision if challenged."  = always denials.

    "Prudent Layperson" Laws Do Not Increase Inappropriate ED Visits (Reuters via Medscape; one-time registration required)

    "However, some compliance problems did emerge. Some insurers, Hall told Reuters Health, initially deny ED claims and then "quickly reverse" their decision if challenged.

     

    "There are two take-home messages for health professionals," Hall said. "One, insurers much less often question the appropriateness of emergency services and two, if insurers initially deny coverage for emergency care, providers or patients should appeal."

     

    The impact and enforcement of prudent layperson laws (Mark A. Hall, JD, Annals of Emergency Medicine Online, May 2004 • Volume 43 • Number 5)

    [ABSTRACT]  [FULL TEXT] [ PDF]

     

    Who Would Decide When to
    Discharge A Patient
    ?
    (Copyright © 2004 by Jin Zhou,  ERISAclaim.com)


    U.S. SUPREME COURT
    Docket for 03-83
     

    ORAL ARGUMENT TRANSCRIPTS (page 16-17 0f 49)

      02-1845. Aetna Health Inc. v. Davila

    03/23/04

    "QUESTION: Yes, but in the situation in the hospital case, there was no time to get relief. How could they -- how could they get relief from the denial of the extra day in the hospital between midnight and the next morning?

    .....

     

    MR. FELDMAN: It's up to her doctor, with whom she has a doctor patient relationship that's a consensual relationship for providing medical treatment. It's up to her doctor to decide when she should be discharged from the hospital and when she shouldn't."

     

     (Page 17-19)

     

    JAMES A. FELDMAN, ESQ., Assistant to the Solicitor General, Department of Justice, Washington, D.C.; on behalf of the United States, as amicus curiae, supporting petitioners.

     

     

    U.S. Health-care Crisis & ERISA Criminal Enforcement

     

    Aetna + CIGNA Settlement
    Demystified

     © 2004  Jin Zhou, ERISAclaim.com

     

    Settlements = ERISA + 3 E. B.

    (Click on each hyperlinks for details)

     

    "Aetna and CIGNA Settlement Secrets"

    "Talking Points"

     

    1. ERISA stands for Employee Retirement Income Security Act

    2. E. B. = External Boards (of Reviews) (§7.10-7.11): 1) Medical Necessity, 2) Billing & Coding and 3) Policy Coverage

    3. Settlements Only for MCO/Provider Contract Disputes

    4. Settlements Not for Patient Coverage/ERISA Disputes, (§7.10-7.11)

    5. Patient Disputes = ERISA/Coverage/Medical Necessity/Bundling & Down Coding

    6. Provider Disputes = PPO Discount/HMO Capitation/Provider Relationship (DOL FAQ A8)

    7. Patient Disputes Provider Disputes, (DOL FAQ A8); Provider/MCO Contract (PPO/HMO) Disputes are not Triggered until Patient ERISA Disputes With the ERISA Plan Are 100% Resolved or Moot (DOL FAQ C12) (PASCACK VALLEY HOSPITAL, INC. v  LOCAL 464A UFCW WELFARE REIMBURSEMENT PLAN (3rd Cir. 11/01/2004)

    8. External Reviews (3 E. B.) Are Not Available until Internal Reviews (ERISA) Completed, (GAO)

    9. ERISA = Federal Law Mandate; External  Reviews = State Law Mandate, (GAO)

    10. No ERISA Compliance = No Rights for Any One

     

     

     

    A New Diagnosis & Solution:
    EFS-- ERISA FAILURE SYNDROME--Fatality: 31 YOA
     

    ERISA Failure, Noncompliance and Nonenforcement of ERISA SPD and Claims Procedure Rules, Is the Damaged or Missing Foam on U.S. Healthcare Wings!

    HMO Crisis Is Really An ERISA Crisis!

    HMO & PPO Managed Care Contracting to 
    Disregard & Substitute
    ERISA SPD & Claims Procedure
    Is The Primary & Inevitable Cause of Medical Inflation

    Costly Managed Care & Medical Malpractice Lawsuits
    American Job Export!

     

    ERISA Failure Damages Are Greater Than
    9/11 and Pearl Harbor Tragedies Combined

    U.S. Health-care Crisis & ERISA Criminal Enforcement

     

    Only practical solution is to cut the skyrocketing healthcare care costs and increase the healthcare coverage and benefits at the same time without having to go to Congress to reinvent another new "Mars Project" or "Universal Uninsured Bill of Right"- "John Q. ERISA Enforcement".

     

    Employers Audit Workers' Health Claims (Wall Street Journal via SFGate.com) & (MLive.com, MI)

    Excerpt: "Looking to bring down soaring health-care costs anywhere they can, more employers are scouring their health plans for fraud, abuse and simple mistakes by employees or administrators.

    .......The number of requests for such audits jumped 50 percent last year, Mr. Farley estimates."

    CMS ISSUES INTERIM FINAL RULE ADDRESSING PHYSICIAN SELF-REFERRALS (CMS News, March 25, 2004)

     


    United States Department of Health and Human Services: Leading America to Better Health, Safety and Well-Being
     

    2004.02.19: Text of Letter From Tommy G. Thompson Secretary of Health and Human Services To Richard J. Davidson, President, American Hospital Association.  

    HHS FAQ "Questions On Charges For The Uninsured" (PDF)

    HHS FAQ's "regarding offering discounts to the uninsured" (PDF)

     

    OIG "HOSPITAL DISCOUNTS OFFERED TO PATIENTS WHO CANNOT AFFORD TO PAY THEIR HOSPITAL BILLS"

     

    Press Release      Complaint (pdf)

     

    U.S. FILES COMPLAINT AGAINST NATIONAL ACCOUNTING FIRM UNDER FALSE CLAIMS ACT

    "January 5, 2004 - PHILADELPHIA – United States Attorney Patrick L. Meehan announced today the filing of the Government's complaint against national accounting firm Ernst & Young. According to the complaint, nine hospitals paid Ernst & Young for billing advice – advice which later caused the submission of false claims to the Medicare program."

    .....

    "It is the responsibility of an independent reviewer to be alert to fraud and abuse and certainly not to ignore it," said Meehan. "In this case, as the complaint alleges, Ernst & Young kept itself deliberately ignorant of the facts."

    OIG: Special Advisory Bulletin: Practices of Business Consultants [PDF] [http://oig.hhs.gov/fraud/docs/alertsandbulletins/consultants.pdf]
    The Office of Inspector General (OIG), Department of Health and Human Services
    , June, 2001

     

    Labor Department Sues Corporation For Violating Federal Employee Benefit Law (Release Date: 02/02/2004)

    "Columbus, Ohio - The U.S. Department of Labor has sued defunct General Clay Products Corporation, of Columbus, Ohio, for abandoning the company’s retirement plan, and also filed suit against its president for failing to forward employee contributions to the health plan. The alleged violations resulted in the loss of health insurance coverage for company workers."

    ‘‘Medicare Prescription Drug, Improvement, and Modernization Act of 2003’’ (pdf) (415) (A full text of the H.R. 1)

    JS-1061: Treasury Issues Guidance To Encourage Use Of New Innovative Health Savings Accounts ("HSAs")

    Text of IRS Notice 2004-2: Guidance on Health Savings Accounts (PDF) (Internal Revenue Service)

    13 pages. Excerpt: "This notice provides certain basic information about HSAs in question and answer format, without attempting to enumerate all of the specific rules that apply under section 223. The notice is divided into five parts. Part I of the notice explains what HSAs are and who can have them. Part II describes how HSAs can be established. Parts III and IV cover contributions to HSAs and distributions from HSAs. Part V discusses other matters relating to HSAs."

    Overview of Health Savings Accounts With Chart Comparison to Archer MSAs, HRAs and FSAs (PDF) (Miller & Chevalier Chartered)

     

    How Health Savings Accounts Compare To FSAs and HRAs (Groom Law Group)

     

    IRS Modifies HSA Eligibility Rule for 2004, 2005 for Individuals Covered by Prescription Drug Plan (PDF) (Internal Revenue Service)

     

    Rev. Rul. 2004-38 Clarifies HSA Eligibility Rule for Individuals Covered by Prescription Drug Plans (PDF) (Internal Revenue Service)

     

    IRS Provides Safe Harbor for Preventive Care Benefits Under High-Deductible Health Plan (PDF) (Internal Revenue Service)

     

    HSAs Established Before April 15, 2005 Can Cover Expenses Incurred On or After January 1, 2004 (PDF) (Internal Revenue Service)

     

    Frequently Asked Questions About Health Savings Accounts (HSAs) (U.S. Treasury Department)

     

    Text of Rev. Rul. 2004-45 on Interaction of Health Savings Accounts with Other Health Arrangements (PDF) (Internal Revenue Service)

     

    JS-1535: Treasury Clarifies Interaction Of Health Savings Accounts With Other Employer-Provided Health Reimbursement Plans

     

    Draft Form Issued by IRS: Model Health Savings Account for Use by Trustees (PDF) (Internal Revenue Service)

     

    Draft Form Issued by IRS: Model Health Savings Account for Use by Custodians (PDF) (Internal Revenue Service)

     

    Text of Notice 2004-50 Providing 88 Q&As on Health Savings Accounts (PDF) (Internal Revenue Service)

    30 pages. Excerpt: "This notice provides guidance on Health Savings Accounts.... Notice 2004-2, 2004-2 I.R.B. 269, provides certain basic information on HSAs in question and answer format. This notice addresses additional questions relating to HSAs."

    Text of Notice 2004-50 Providing 88 Q&As on Health Savings Accounts (PDF) (Internal Revenue Service) (Revised and corrected--Aug. 9, 2004)  32 pages

     

    IRS Announcement 2004-67 (Sept. 7, 2004) (page 54 of 57)

    CORRECTIONS
    "The last sentence in A–14 of Notice 2004–2 which currently reads, “After an individual has attained age 65 (the Medicare eligibility age), contributions, including catch-up contributions, cannot be made to an individual’s HSA”, is corrected to read as follows: “After an individual has attained age 65 and becomes enrolled in Medicare benefits, contributions, including catch-up contributions, cannot be made to an individual’s HSA.” Additionally, the terms “becomes eligible for” in the first sentence of the Example in A–14 of Notice 2004–2 are replaced by “becomes enrolled in”.

    Final Versions of Combined HSA/Archer MSA Reporting Forms and Instructions for Trustees and Custodians: Form 1099-SA and Instructions  Form 5498-SA

     

    Analysis: Comprehensive HSA Guidance Clarifies Many Issues, Sets Forth Several New Rules (Groom Law Group)

     

    Text of Proposed Regs for Medicare Prescription Drug Benefit (PDF)
    233 pages. (Centers for Medicare & Medicaid Services, Department of Health and Human Services)

     

    ERIC Summary Outline for Employer Sections (Title 1; J & R) of the Medicare Regulations (ERISA Industry Committee)

     

    ABA Joint Committee on Employee Benefits Agency Q-As

     

    ABA Reports Various Employee Benefit Regulators' Views on Health Issues (Deloitte's Washington Bulletin)

     

    Overview: 2005 Medicare Premiums, Deductibles and Coinsurance (The Segal Company)

     

     

    New Seminar in Ohio
    New federal law/ERISA Preservice Claims
    Pre-certification Denials and Appeals

     

     

     

    Breaking News

     

    Judge approves $540 million Cigna settlement with doctors

    950,000 Physicians Agreed to Do ERISA Appeals in
    Settlement of Physician Class-Action Lawsuits

    Judge Approves Aetna Settlement (CNN, 10/25/03)

    "Aetna and CIGNA Settlement Secrets"

    "Talking Points"

    What You Should Know about Filing Your Health Benefits Claim

     

    Did you know that 950,000 physicians nationwide have settled and agreed with Aetna and CIGNA in their class-action lawsuit that 950,000 physicians must complete two levels of ERISA appeals as health plans internal appeals for both ERISA claims and non-ERISA claims before they can access the state protections through state external review laws?

     

    Did you know that 40 states require the completion of ERISA appeals by physicians or patients as health plan internal appeals before anyone can claim stayed law protections through state external review laws?


     

    Ask your state association for more details on how to complete ERISA appeals for your denied and delayed medical claims.

     

    Click here for class-action lawsuit agreements with Aetna and CIGNA.

     

    Federal Judge Permits Doctors To Seek Damages From HMOs for Violating RICO Act (KaiserNetwork.org)

    Judge Sides With Doctors Over Insurers ( New York Times )

     

    Nearly Sixty Blue Cross/Blue Shield Affiliates throughout the Country Sued by Physicians (HMO Crisis Newsroom)

    *00-1334-MD Transfer Order - 09/25/03 (pdf)

    Thomas/Kutell, MD v. BCBS, Case #03-21296 - Judge Dubé

    May 22, 03  Plaintiffs' Class Action Complaint / Part 1 / Part 2

    May 22, 03  Civil Rico Case Statement Pursuant to Local Rule 12.1

    Jun 29, 04 Subpoena Duces Tecum: National Account Service Company LLC (produce docs: 7/27/04)

     

    Jun 18, 04 Plaintiffs' Second Amended Class Action Complaint

     

    Jun 28, 04  Solomon:  First Amended Complaint - Class Action
     

    "Forty states required individuals to first exhaust their health policy’s internal appeals and grievance process before seeking external review." (GAO, September 2003, Page 46)  The health policy’s internal appeals and grievance process = ERISA appeals for 80% of the health claims.

    "GAO was asked to summarize current federal and state requirements for health coverage offered by small businesses, including mandated benefits, premium-setting requirements, and requirements regarding availability of coverage."

     

     

     

    What's    ???   ???    ???   New  ??  ?   

    New Federal Claim Regulation (Final Rule)
    Benefit Claims Procedure Regulation (FAQ)
    Amendments to Summary Plan Description Regulations
    (Final Rule)
    Patient's Rights Claims Procedure Regulation (Fact Sheet)

    What You Should Know about Filing Your Health Benefits Claim

     

    Effective January 01, 2003

     

     You Must Be in Compliance

     

    How to Obtain Employee Benefit Plan Documents from the Department of Labor

     

    DOL Document Requests: Summary Plan Descriptions within 10 days

    DOL Forms & Document Requests page

    DOL Handling Complaints

     

    HHS Posts Additional Q&As About April 14, 2004 Small Health Plan HIPAA Compliance Date (U.S. Department of Health & Human Services)

     

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

     

    Health Care Claim Appeals Are Not Subject to HIPAA's Standard Transactions Rules  [CMS Frequently Asked Questions (FAQs) on HIPAA Administrative Simplification (Updated Nov. 6, 2003)]

    Is a health care claim appeal considered a HIPAA-adopted standard transaction?    "No." (CMS, 11/06/2003)

    Labor Department Issues Reporting And Disclosure Guide for Employee Benefit Plans (11/20/2003)  

    Reporting and Disclosure Guide for Employee Benefit Plans (U.S. Department of Labor Employee Benefits Security Administration)  pdf

    Text of DOL Field Assistance Bulletin: Voluntary HSAs Generally Not ERISA-Covered Plans (U.S. Department of Labor, Employee Benefits Security Administration)

     

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

     

     

    Free Update - ERISA Books & Appeal System

    Last updated 03/06/2004

     

    1 FREE 2003 Update: (PDF) Available for Download

     

    2

    FREE 2003 Update: (MS Word/Doc) Available for Download

    Update in Compliance with New SPD and Claim Procedure Rules

     

    3 FREE 2003 Update: (MS Word/Doc) Available for Download for


    Free 2003 Update: Bundling & Down Coding/PPO Discount
    under New ERISA Claim Regulation and Supreme Court Unanimous Ruling

     

    4 Free 2003 Update, No SPD & "Not Plan Administrator"

     

    5 Free 2003 Update: "Overpayment" Refund Request Response & Appeals (Doc)

     

    6 Free 2003 Update: New  SPD Request Letter, Compliant with New ERISA Claim Regulation and HIPAA Rules, Important Update,

     

    7 Free 2003 Upadte: ERISA Preservice Claim Form

     

    8 Free 2004 Update "ERISA Quick Guides"

     

    9 Free 2004 Update "ERISA Assigment Dispute" (09/16/2004)

     

     

    New Federal Claim Regulation (Final Rule)

     

    After a one year delay, New Federal Benefit Claims Procedure Regulation has become effective January 01, 2003 for almost all of the private group health plans. It will affect about 80% of health-care claims or 60% of health expenditures, approximately 6 million private health and welfare plans and approximately 150 million workers and their dependents  in the U. S..

     

    "The regulation will affect participants and beneficiaries of employee benefit plans, employers who sponsor employee benefit plans, plan fiduciaries, and others who assist in the provision of plan benefits, such as third-party benefits administrators and health service providers or health maintenance organizations that provide benefits to participants and beneficiaries of employee benefit plans."

    The Regulation is the most significant change in health-care laws since 1977, and it has been considered by congressional leaders to be more powerful than proposed Patients Bill Of Rights. "The regulation establishes new standards for the processing of claims under group health plans and plans providing disability benefits and further clarifies existing standards for all other employee benefit plans. The new standards are intended to ensure more timely benefit determinations, to improve access to information on which a benefit determination is made, and to assure that participants  and beneficiaries will be afforded a full and fair review of denied claims."

    Contrary to the popular belief, the new federal claim regulation provides more protections for physicians and patients than state insurance and Prompt Pay Laws, and more protections and clarifications for insurance companies and the ERISA plan sponsors as well as the third party benefits administrators than state laws in punitive damages as proposed in Patients Bill Of Rights.

     

    However, failure to understand and comply timely with the regulation  will invite and suffer from unanticipated financial and legal consequences.

     

    AMA has finally noticed the existence and effective date of this new federal claim regulation, as described in its January 20, 2003 online edition of American Medical News: "Federal regulations that dictate rapid turnaround times for health plan claims and appeals quietly went into effect this month, with little noise from the managed care industry."


    However AMA has failed, as it did in past 28 years, to practically and meaningfully understand the ERISA and its significance as protections for health-care providers, entire industry has failed to offer any educational programs and occupational trainings to health-care providers in this most important federal law and regulation that governs and regulates up to 80% of health-care claims and 60% of U.S. healthcare expenditures.

     

    As reported by AMA as to the time it may take for this new federal claim regulation to take effect in marketplace, Jeffery Mandell, president of the ERISA Law Group in Boise, Idaho, states "it often takes years, even decades, for the marketplace to fully adopt new regulations". Life is too short, our nation's health-care system is going through the worst crisis since World War II and can't afford another 28 years to realize and implement the ERISA regulations. We, everyone including health-care providers, legislators, regulators and insurance companies and TPA's, should take immediate actions to educate everyone in the system and to implement this new federal claim regulation as we are fighting against terrorists to save our nation's health-care system from worse-than-terror-war crisis.

     

    The latest Harvard & RAND study for Congress and state legislative debate on Patients' Bills of Rights, conducted by David Studdert and Carole Roan Gresenz, study authors from the Harvard School of Public Health and RAND, funded by federal government, Department Of Labor, and Agency for Health Care Research and Quality, revealed that "little is publicly known about such appeals system", and concluded that "A majority of preservice appeals disputed choice of provider or contractual coverage issues, rather than medical necessity. Medical necessity disputes proliferate not around life-saving treatments but in areas of societal uncertainty about the legitimate boundaries of insurance coverage. Greater transparency about the coverage status of specific services, through more precise contractual language and consumer education about benefits limitations, may help to avoid a large proportion of disputes in managed care.

     

    A JAMA Editorial commenting this study further supported the conclusion of this study and advanced the right solutions more precisely at New ERISA Claim Regulations: "Regulations issued by the Clinton administration in 2000 were designed to infuse rigor into the appeals process maintained by employer-sponsored health plans covered by the Employee Retirement Income Security Act (ERISA),10 which governs insurance arrangements for more than 150 million workers and their family members. Whether these rules will be vigorously enforced remains to be seen."

     

    This valuable study has pointed out the direction but failed to provide a turnkey practical solution.


    ERISAclaim.com has provided this nation with a turnkey operational solution with ERISA compliance, to educate everyone on ERISA, coverage and claim procedures, to ensure "Bill Of Rights" for Patients, Providers, Plan Sponsors and Insurers.

     

       Aetna (DOL/ERISA), First Health, Blue Cross Blue Shield are ready to comply with new federal regulation (BCBSIL) (BCBSMI) (BCBSCNY) (BCBSNE) (CareFirstBCBS) & (BCBSAL),  are you ready to get paid faster and fairer?

     

    From Aetna's ERISA yesterday (Aetna Video Shows ERISA Patients Mistreated) to Aetna's ERISA today (DOL/ERISA) = Aetna ERISA Actions or intention in compliance and in control.

     

    From AMA's ERISA yesterday (The latest Harvard & RAND study) to AMA's ERISA today (JAMA Editorial) =ERISA Actions or Not?

     

    That's why physicians, healthcare providers and hospitals must wake up on ERISA now!

     

    "Forty states required individuals to first exhaust their health policy’s internal appeals and grievance process before seeking external review." (GAO, September 2003, Page 46)  The health policy’s internal appeals and grievance process = ERISA appeals 80% of the time.

     

    "Congress library report", "Minneapolis memorandum" and "Phoenix memorandum" should have been sufficient intelligence for executive decision-making on health-care Oct. 11 fact card.

     

     

     

    Brief Summary Of the New Regulation

    for Physicians and ERISA Plans/TPAs

    Effective Date: January 01, 2003

     

    For Physicians and Health-care Providers

    For Insurance Companies
    ERISA Plans/TPAs

    ERISA's Prompt Pay Law, better than State Prompt Pay Laws  [29 CFR § 2560.503-1 (f)(i), Page 70267-9] ERISA's Prompt Pay Law, better than State Prompt Pay Laws [29 CFR § 2560.503-1 (f)(i), Page 70267-9]
       
    New Assignment of Benefit Form Required for Appeals and Claim Dispute (DOL FAQ, B2-B3) No New Legal Assignment of Benefit Form, No Obligations to Physicians and Health-care Service Providers (DOL FAQ B2), otherwise Obligations to Disclose to Both Patients and Providers (DOL FAQ B-3)
       
    No written appeal, no rights, except for claims involved with urgent care. [Page 70255 & 70271] In claims involved with urgent care, physicians/health-care providers are to be considered by default as authorized representatives. [Page 70255 & 70271]
       
    The regulation clarifies for the first time since 1977 and prohibits anti-assignment provisions in ERISA plans & (footnote 36). [page 70255 ] [29 CFR § 2560.503-1 (b) (4) Page 70266] Assignments by patients must be absolutely clear as to what extent and capacity, verifications are permitted & (footnote 36). (DOL FAQ B-3) [page 70255 & 70266] [29 CFR § 2560.503-1 (b) (4), Page 70266]
       
    Must complete required two levels of appeals, with legal assignment of benefits and specific written request for disclosure of specific plan documents. [Page 70253] No legal assignment of benefits, no response required; no specific written request, no disclosure obligated, however failure to establish and comply with claim procedures, administrative remedies are considered to be exhausted. Lawsuit may follow. [Page 70271]
       
    New protections for pre-service claims and urgent care claims against improper pre-authorization, pre-certification and utilization review as well as urgent cares. [Page 70248 & 70271] Understanding of differences in pre-service, urgent care and post-service claims will save big money in fiduciary breach liability claims and POSSIBLE medical malpractice claims[Page 70248 & 70271]
       
    New definitions of relevant documents and disclosure obligations, no more medical necessity secrets, UCR fee schedule confidential [Page 70252]  [29 CFR § 2560.503-1 (h)(2)(iii) (m) (4), Page 70268, 70271] [DOL FAQ B-5] No legal assignment of benefits, no obligation to disclose to an assignee, assignment verification by the plan is allowed and protected. Update SPD and any guidelines, only use disclosable and qualified medical claim reviewers. [Page 70252]  [29 CFR § 2560.503-1 (h)(2)(iii) (m) (4), Page 70268, 70271] [DOL FAQ B-5]
       
    A Full and Fair Review with new definitions and protection requires de novo reviews on two appeals by at least four different people, two different fiduciaries with ERISA plan, and two different Health-care professionals independent to the ERISA plan. [29 CFR § 2560.503-1 (h) (3)(ii)(iii)(iv)(v), Page 70268-9, (m) (8), Page 70271] [Page 70252-70253] Update SPDs with New Standards and compliance, specify and designate only qualified fiduciaries for appeals, establish new complaint appeal procedures, use only disclosable and licensed as well as certified health-care professionals for medical reviews, pre-certification and prior authorizations in every case. [29 CFR § 2560.503-1 (h) (3)(ii)(iii)(iv)(v), Page 70268-9, (m) (8), Page 70271] [Page 70252-70253]
       
    New clarifications on state law preemptions and "independent" medical reviews. No preemption for state laws unless prevention of the application of the new regulation [Page 70254] Comply with both the regulation and state laws in claims involving mixed treatment and eligibility determinations and pure medical treatment decision-makings. [Page 70254]
       
    New clarifications with new definitions claim denial/an adverse benefit determination  (payment<100% claimed) or Overpayment, and new protections. (DOL FAQ C-12) Overpayment vs. an adverse benefit determination, recoupment vs. appeal procedures. (DOL FAQ C-12)
       
    SPDs must describe...... No SPDs, No decision making
       
    Insurance company's decision-making power and disclosure obligations must be described in SPD [29 CFR 2520.102-3 (q), Page 70242] Fully-insured plans with a health insurance issuer being wholly or partially responsible for administering the plan (e.g. payment of claims) must describe insurer's role in SPD. [29 CFR 2520.102-3 (q), Page 70242]
       
    Claim fiduciary, whoever makes denial appeal decisions, has duties to disclose SPD and relevant document [29 CFR § 2560.503-1 (h)(2)(iii), (3)(iii) Page 70268-9, (m) (8), Page 70271] or may face up to $110 a day penalty under "Prudent Actions by Plan Fiduciaries" and "Enforce Your Rights."  [29 CFR § 2520.102-3, Page 70243]  Claim fiduciaries or plan fiduciaries have new duties to disclose, without charge, SPD and relevant document [29 CFR § 2560.503-1 (h)(2)(iii), (3)(iii) Page 70268-9, (m) (8), Page 70271] when claim for benefits is denied or delayed, or may face up to $110 a day penalty under "Prudent Actions by Plan Fiduciaries" and "Enforce Your Rights." [29 CFR § 2520.102-3, Page 70243] 
    Failure to timely make benefit determination and review decisions by the plan administrator will constitute "deemed denied" review/appeal and "deemed exhaustion of administrative remedy" under § 2560.503-1(l), ("a decision on the merits of the claim" = de novo judicial review, instead of deferential judicial review) that will forfeit or preclude the plan from "deferential review standard" on judicial review in federal court, the most important part of "ERISA Shield" on ERISA land Gilbertson v Allied Signal Inc

    DOL interprets § 2560.503-1(l) through CFR accompanying supplementary information on page 70255: “The Department’s intentions in including this provision in the proposal were to clarify that the procedural minimums of the regulation are essential to procedural fairness and that a decision made in the absence of the mandated procedural protections should not be entitled to any judicial deference.”

    More.... More....

     

    And many more new and important provisions and protections for health-care providers and insurance companies/ERISA plans/TPA's, as well as patients and employers.

     

    Surprisingly and ironically, under current national health-care crisis for everyone, most of us, healthcare providers, payers and administrators, patients and employers, are not ready for this new federal claim regulation, its meaningful and practical compliance and enforcement may save all of us from worsening of national health-care crisis.

     

    Don't wait for another 28 years, it's not too late to take actions to become in compliance for your own benefits and protections.

     

    Our seminars are for everyone, physicians, health-care providers, clinics, hospitals, insurance companies, ERISA plans, third party claim administrators and plan sponsors as well as state insurance regulators.

     

    Only with understanding of the regulation and other partners and alliances in our nation's health-care system, our national health-care system will survive and prosper.

     

     

    The Most Powerful & only Seminar in the U.S.
    Focused on Health Care
    ERISA Claim Regulation Compliance & Appeals For Everyone!

     

    Details on Seminar Page

     

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

     

    Call 630-736-2974    FAX to (630) 736-1439

    Only One Payment from Your Denied Claims
    May Pay off the Seminar or Book Itself!
    Why Not Take Actions to Save 40% of Your Business & Headaches?

     

        Due to the recent demand from the ERISA plans and TPA's, we're pleased to announce that we also provide educational and consulting services to the ERISA plans, TPA's and managed care organizations on New Federal Claim/ERISA Regulations and Compliance, however we do not provide any services involving actual claim dispute or legal advice for any legal matter or disputes.

     

     


    Payments Go Under a Microscope (washingtonpost.com)

    January 12, 2004

    "CareFirst officials said the audit of 2,800 doctors was triggered by an earlier examination of several thousand claims that found 9 of every 10 were inaccurate. "The doctors, we're not saying we don't trust them," said Jeff Valentine, a CareFirst spokesman. "But as President Reagan said a number of years ago: 'Trust, but verify.' "

     

    "The largest insurer of all, the federal government, recently estimated that the Medicare program overpaid doctors, hospitals and other health-care providers by $11.6 billion in 2002, according to an audit of 128,000 claims. The audit found many providers submitted insufficient documentation (45 percent), billed for medically unnecessary services (22 percent) and used incorrect codes to describe patient visits (12 percent)."

     

    "A larger audit is planned this year. "The digging now is much deeper," said Leslie V. Norwalk, chief operating officer of the Centers for Medicare & Medicaid Services, the government agency known as CMS. "Any dollar overpaid is a dollar too much."

     

    "MAMSI and CareFirst recoup overpayments to doctors by making deductions from future reimbursements. Doctors can appeal insurers' decisions. But, in the end, they usually pay up, doctors and insurers agree."

    Forbes.com: "Roughly one in seven Americans has no health insurance. That hurts HCA Inc. (nyse: HCA - news - people), the largest U.S. hospital chain, which last year wrote off $2.21 billion of revenue because patients couldn't pay their bills."
     

    The American Hospital Association (AHA): "Hospitals today are faced with the challenge of managing their limited resources, while continuing to deliver the highest standard of care. According to health care experts, the cost of clinical denials to individual healthcare organizations averages $3.3 million annually. However, many hospitals do not have the resources or the expertise needed to avoid unpaid days at the end of admissions and lead the denial-appeals processes."

     

     

    ERISA OVERHAUL OF U.S. HEALTHCARE FOR SURVIVAL

     

    "Zhou's Model of Prudent Health Care"

    Are All Consultants Corrupt? (Fast Company)

        The First Overhaul for U.S. Health care and GM Is to ERISA-Overhaul GM Health Care Model with Followings:

    1. ERISA Compliant SPD with Complete Benefits Coverage, Limits & Exclusions;

    2. ERISA Compliant Claims Procedure as the Only Rule for Every One;

    3. Elimination of Any Third-Party Managed Care Contracts, UCR & "Medical Necessity"

    (GM Current Model: $5.1 billion/yr, $1,400/vehicle)
    (GM says health care obligation hit $67.5 billion in 2003)

    Rx-1  $$$$$$$$$ERISA"Health Insurance Challenges: Buyer Beware" 3-3-04
Hearing, Senate Committee on Finance
$$$$$$$$$$  Rx-2

    General Motors National Benefit Center

    Health Spending Projections Through 2013

    New Federal Claim Regulation (Final Rule)
    Benefit Claims Procedure Regulation (FAQ)
    Amendments to Summary Plan Description Regulations
    (Final Rule)
    Patient's Rights Claims Procedure Regulation (Fact Sheet)

    U.S. Health-care Crisis & ERISA Criminal Enforcement

    CBO's analysis of the President's budgetary proposals for fiscal year 2005

     

     

    DOL-Reporting and Disclosure Guide for Employee Benefit Plans (pdf)
    Compliance Assistance for Group Health Plans (Top 15 Tips)

    950,000 MD's Settled With Aetna & Cigna on ERISA
    "Aetna and CIGNA Settlement Secrets"
    ERISA Certification Programs for Maximal Reimbursement

    What You Should Know about Filing Your Health Benefits Claim
    HIPAA Nondiscrimination Requirements Frequently Asked Questions

     


    U.S. Health-care Crisis
    & ERISA Criminal Enforcement



    ERISAclaim.com - A $1.0 Trillion Nuclear Solution to U.S. Health-care Crisis & $44 Trillion Budget Deficits

     

    ERISAclaim.com: 50% Savings - Healthcare Crisis Turnaround for Employers, Insurers & TPA's

     

    ERISAclaim.com - 950,000 MD's Settled With Aetna & Cigna on ERISA

     

    ERISAclaim.com:  ERISA Certification Programs
    for Cost-Saving & Reimbursement by Compliance

     

    ERISAclaim.com - U.S. Health-care Crisis
    & ERISA Criminal Enforcement

     

     

    DOL + DOJ Enforcement of ERISA

     

        

     

    HHS Works with ERISA (+77 Millions/4 Yrs)

     

     

     

    Denials + Recoupment = Inflation + Fraud or Cost-Sharing?

    Rx = Compliant Denials & Appeals!

    Forbes.com: "Roughly one in seven Americans has no health insurance. That hurts HCA Inc. (nyse: HCA - news - people), the largest U.S. hospital chain, which last year wrote off $2.21 billion of revenue because patients couldn't pay their bills."

     

    The American Hospital Association (AHA): "Hospitals today are faced with the challenge of managing their limited resources, while continuing to deliver the highest standard of care. According to health care experts, the cost of clinical denials to individual healthcare organizations averages $3.3 million annually. However, many hospitals do not have the resources or the expertise needed to avoid unpaid days at the end of admissions and lead the denial-appeals processes."

     

    Payments Go Under a Microscope (washingtonpost.com) "MAMSI and CareFirst recoup overpayments to doctors by making deductions from future reimbursements. Doctors can appeal insurers' decisions. But, in the end, they usually pay up, doctors and insurers agree."

     

    Hospital Pricing and the Uninsured, Glenn Melnick, Ph.D., "Price Gouging"
    (Subcommittee on Health
    Hearing on the Uninsured, Tuesday, March 09, 2004)

     

    U.S. FILES COMPLAINT AGAINST NATIONAL ACCOUNTING FIRM UNDER FALSE CLAIMS ACT (DOJ Press Release"January 5, 2004 - PHILADELPHIA – United States Attorney Patrick L. Meehan announced today the filing of the Government's complaint against national accounting firm Ernst & Young. According to the complaint, nine hospitals paid Ernst & Young for billing advice – advice which later caused the submission of false claims to the Medicare program."

     

    USATODAY.com - Hospitals Sock Uninsured with Much Bigger Bills

    GM to Report $60B in Future Health-Care Obligations

     

     

    DOL Compliance Assistance for Health Plans

     

     

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

            Selected links:

    Sec. 1002.
    Definitions

    Sec. 1003.
    Coverage

    Sec. 1022.
    Summary plan description
    Sec. 1104.
    Fiduciary duties

    Sec. 1140.
    Interference with protected rights

    Sec. 1141.
    Coercive interference

    part 7
    group health plan requirements

     

    Code of Federal Regulations

    Codified in Title 29 of the Code of Federal Regulations:

    Regulations

            Selected links:

    2520.102-3 Contents of summary plan description.
    2560.503-1 

    Claims procedure.

     

    ERISA Laws/Rules

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

    ERISA in US CODE

     

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

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

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

    DOL

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

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

     

    Fact Sheet - What To Do If Your Health Coverage Can No Longer Pay Benefits

     

    Questions and Answers: Recent Changes in Health Care Law (PDF)

     

    Continuation of Health Coverage – COBRA

     

    HIPAA Nondiscrimination Requirements Frequently Asked Questions

     

    HHS Press Release:
     

    2004.02.19: Text of Letter From Tommy G. Thompson Secretary of Health and Human Services To Richard J. Davidson, President, American Hospital Association.  

    HHS FAQ "Questions On Charges For The Uninsured" (PDF)

    HHS FAQ's "regarding offering discounts to the uninsured" (PDF)

     

    OIG "HOSPITAL DISCOUNTS OFFERED TO PATIENTS WHO CANNOT AFFORD TO PAY THEIR HOSPITAL BILLS"


    National Correct Coding Initiative Edits - Version 11
     

    National Correct Coding Edits for the Hospital Outpatient PPS - Version 10.3


    2003 Improper Medicare Fee-for-Service Payments Report

     

    CMS Announces Revisions to Payment for Drugs and Physician Fee Schedule Payments for Calendar Year 2004

     

    Medicare Announces 2004 Physician Fee Schedule and Payment Policy Changes

    CMS Files for Download for Medicare Payment Systems

     

    CMS Finalizes Appeals Process for Medicare Coverage Decisions

     

    2003.12.10: HHS Announces Immediate Steps to Make Medicare-Approved Drug Discount Card Programs Available Next Spring

     

    42 CFR Parts 403 and 408
    Medicare Program; Medicare Prescription
    Drug Discount Card; Interim Rule and Notice (pdf) (89 pages)

     

    Revision of Billing Instructions for Purchased Services
     

    Regional Offices Link


    WPS Medicare Part B - 2005 Medicare Payment Information Available from CD-Rom

     

    HIPPA Final

    AMNews through  AMA

    Health plans subject to new federal appeals rules
    Much-postponed regulations offer patients and doctors fairer and faster review, plus new rights, Dept. of Labor says.
    ERISA Not Insurance

    Aetna Video Shows ERISA Patients Mistreated

     

    "According to the video, when faced with claims for identical medical problems, Aetna separates the claims where no damages are available - those subject to the federal Employee Retirement Income Security Act, or ERISA - from non-ERISA claims, where consumers can sue.1 2"

     

    Aetna Reaches Agreement with Physicians, May 22, 2003 (Aetna.com)

     

    Managed Care and Patients' Rights
    (JAMA Editorial)

     

    $10,600 ERISA Claim

    Recent Federal Court Ruling in a Case with $10,600 medical claim, insurance Co. refused to pay, provider made numerous demand for payment in almost one year, but no appeals filed, the court dismissed the lawsuit because provider failed to exhaust administrative remedy, as required under ERISA, by filing ERISA claim appeals.  This situation is so popular in health-care community.

     

    $37,350 ERISA Claim

    Health-care provider alleged medical claims submitted to Aetna for reimbursement, Aetna asserted no receipt of medical claims, no written denials.  Health-care provider failed to present proof of claim submission, claim denial and ERISA claim appeals. This case was dismissed. ERISA health-care claims are handled in federal court, state law is generally not applicable.

     

     

    PACIFIC COAST HOSPITAL v. AETNA HEALTHCARE

    "requesting payment of benefits and/or to discuss the matter in further detail" by hospitals are wasting time and money

     

    One Employee, One Shareholder, But ERISA Plan

    (Name of the Game for 80 Percent of Health-care Claims in U.S.)

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

    NHPF Publications  

    NHPF Publications  

    NHPF Publications  

     

    2002 Employee Health Benefits Survey (Kaiser Family Foundation)

     

    Survey: Employee Benefits in Private Industry (2000) (U.S. Department of Labor, Bureau of Labor Statistics)

     

    Government Survey: Employee Benefits in Private Industry, 2003 (U.S. Department of Labor, Bureau of Labor Statistics)

     

    Are more workers covered by traditional fee-for-service plans, HMOs, or PPOs?

     

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

     

     

    DOL Secretary Testifies to Committee About ERISA Enforcement, Compliance Assistance (U.S. Department of Labor, Pension and Welfare Benefits Administration)

     

    Study: Health Insurance Premiums Rose More Than 30 Percent Between 1996 and 2000 (U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality)

     

    Opinion: Cutting Costs in Half Through Better Management is Fantasy But Health Care Debate Is Real (The Hartford Courant)
    Excerpt: "If a talk on economics can have a $650 billion throwaway line, Treasury Secretary Paul O'Neill delivered it.... "

     

    "O'Neill insists the problem is not with people, but systems - systems that invite medical errors, systems that penalize health care professionals for making honest mistakes, systems that create the mind-numbing complexity of reimbursement for providers, systems that reward too much treatment and punish efficiency."

    ctnow.com

     Health Cost Trends Shift

    "The study said managed care probably has squeezed out all the savings it can from the nation's health care system and that employers are turning to other familiar devices such as increasing premiums and co-payments to trim their costs"

     

    Independent Medical Review Experiences in California (California HealthCare Foundation)

     

    Health Care Issues Stymie Congress (The Hartford Courant)

     

    Kinder and Gentler: Physicians and Managed Care, 1997-2001 (Center for Studying Health System Change)

     

    Employer Spending on Health Care: 1987-2000 (Employee Benefit Research Institute)

     

    Employer Health Benefits: 2002 Annual Survey.(pdf)
    Accessibility verified January 30, 2003
    (KaiserNetwork.org)

     

     

    National Compensation Survey: Employee Benefits in Private Industry in the United States, 2000 (PDF) (U.S. Department of Labor, Bureau of Labor Statistics)

     

    Government Survey: Employee Benefits in Private Industry, 2003 (U.S. Department of Labor, Bureau of Labor Statistics)

     

     

     

    GAO Report: Improvements to Retirement Income Data Needed (U.S. General Accounting Office)

    "What GAO Recommends:

    The Congress should consider directing Labor to obtain from plan administrators electronic filings of SPDs and summaries of material

    modifications and make them publicly available."

     

     

     

     

     

    Uninsured Reached

    45 Million in 2003
    US Census Press Releases

    "The number of people with health insurance increased by 1.0 million to 243.3 million between 2002 and 2003, and the number without such coverage rose by 1.4 million to 45.0 million."

     

    Income, Poverty, and Health Insurance Coverage in the United States: 2003 (P60-226) new
     

    Health Insurance Data (Source: U.S. Census Bureau)

    (10 years on the web)


    Benefits cost cited in US hiring slump
    Washington Times, DC - Aug 19, 2004

     

     

     

    Sourcebook: Covering Health Issues 2004 (Alliance for Health Reform)

     

     

     

     

     

     

     

    DOWNLOAD ENTIRE SOURCEBOOK (pdf, 5MB)

     

    2005 State Legislators' Guide to Health Insurance Solutions and Glossary (PDF) (The American Legislative Exchange Council and The Council for Affordable Health Insurance)

     

     

    FDA Logo links to FDA home page

    New Super Search

     

     

     

    FDA > CDRH > Database Super Search

     

    "Device Listing Database

     

    Proprietary Device Name:

    MASSAGER ( THERAPUTIC, ELECTRIC, WATER

    Common/Generic Device Name:

    ASOOTHE/AQUAMED

    Classification Name:

    MASSAGER, THERAPEUTIC, ELECTRIC

    Device Class:

    1

    Product Code:

    ISA

    Regulation Number:

    890.5660

    Medical Specialty:

    Physical Medicine"

     

    Categorization of Investigational Devices

     

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

     

     

     

    Agree to terms and conditions

    "Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply."

     

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

     

    UnitedHealthcare Medical Policies

    "By clicking "I agree," you agree to be bound by the terms and conditions expressed below, in addition to our Site Use Agreement.

    UnitedHealthcare medical policies have been made available to you as a general reference resource. When reading these policies you agree that:

    Our Medical Policy is not your patient's Benefit Plan.

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

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

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


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

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     
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