Source: http://erisaclaim.com/Pre-Payment_Review_Denials_%26_Appeals.htm
Timestamp: 2017-01-21 10:37:48
Document Index: 23823536

Matched Legal Cases: ['§2560', '§2719', '§2560', '§2560', '§ 2560', '§1132', '§1056', '§1132', '§2719', '§2719', '§2560', '§2719']

ERISAclaim.com - Pre-Payment Review Delays and Denials – Deemed Denial ERISA Appeals - Healthcare Revenue Cycle Crisis Turnaround Pre-Payment Review Denials
Healthcare Revenue Cycle Crisis Turnaround: Pre-Payment Review Delays and Denials – Deemed Denial ERISA Appeals © JIN ZHOU, President, ERISAclaim.com
New ERISA Appeal Books & Webinars Announced From ERISAcaim.com To Resuscitate Revenue Cycle Crisis With Right Federal Law Magic. Providers Are Seemingly Left With No Common Remedies In Wake Of Financial Debilitating Overpayment Demand And Recoupment From Payers, An Increasing Number Of Healthcare Providers Are Also Facing Bankrupting Pre-Payment Review Delays For Up To Over A Year Of No-Pays And Real Denials, In An Unprecedented U.S. Healthcare Avatar: No Payment From Insurance Companies But Pay Back To Insurance Companies By Providers. Once Informed Of Pre-Payment Reviews, All State Prompt Pay Laws No Longer Apply. New ERISA Appeal Books Will provide The Most Powerful Solutions to the Pre-Payment Review Denials and Appeals
The healthcare providers are seemingly left with no common remedies
in wake of financial debilitating overpayment demand and recoupment from payers, and an increasing number of healthcare providers are also facing bankrupting pre-payment review delays for up to over a year of no-pays and real denials, in an unprecedented U.S. Healthcare Avatar: no payment from insurance companies but pay more back to Insurance Companies by healthcare providers. Once informed by a payer of pre-payment reviews, all state prompt pay laws no longer apply, because no state laws will ever mandate prompt pay for disputed or non-covered claims, and state laws do not govern ERISA plans, both self-insured and fully-insured employment-based health plans. Practically, many healthcare providers are now left with no meaningful remedies while hopelessly crying on sinking Pre-payment Review Titanic for inevitable bankruptcy declaration. New ERISA Appeal Books & Webinars have been announced from ERISAcaim.com to resuscitate revenue cycle crisis with right federal law magic. Federal ERISA pre-empts any and all state laws and managed-care contracts in all money or benefits dispute with ERISA plans, and ERISA provides with most powerful remedies for healthcare providers and insured working Americans: under ERISA §2560.503-1(f)(2)(iii)(B), all post-service claims under pre-payment reviews with or without request for additional information must be decided within 30 with no record request from providers, or within 45 days, including 15 days after receiving the additional records, or the plan must provide claimant with a valid ERISA EOB, Explanation of Benefits, for immediate ERISA full and fair appeals for all deemed denials.
One of the most popular and costly misconceptions for all providers is turning to the state prompt pay laws and PPO contracts for remedies when the providers were informed by payers of pre-payment reviews and were put on Moon Project schedules. State prompt pay laws are not triggered or no longer applicable as soon as a payer takes an action to review the claim with a timely notice within the time lines as provided by the state prompt pay laws, as common sense will tell you that no state prompt pay laws will ever mandate for a payment for disputed or non-covered services.
More importantly, no state prompt pay laws will apply to or govern any ERISA plans, especially self-insured plans.
U. S. Supreme Court unanimously and repeatedly ruled that federal law, ERISA, completely pre-empts all state laws in all benefits dispute with an ERISA plan in all pre-payment and post-payment benefits reviews, in Aetna v. Davila in 2004, and ERISA provides no exemptions for plan administrators to act, to make pre-payment and post-payment review decisions, in accordance with ERISA and the relevant plan documents, regardless of SIU’s (Special Investigation Unit) and PPO’s, in Kennedy v. Plan Administrator for Dupont in 2009.
On March 23, 2010, President Barack Obama signed into law the Patient Protection and Affordable Care Act, PPACA. Effective upon the enactment of the PPACA on 03/23/2010, every group health plan and individual policy issuer must comply with effective internal and external appeal process by incorporating or adopting ERISA claim regulation and NIAC External Review Model Act for any claim denials and overpayment dispute. effective from March 23, 2010, §2719(a)(1)(A)(C) of PPACA requires every group health plan and health insurance issuer for individual coverage to “(A) have in effect an internal claims appeal process” and “(C) allow an enrollee to review their file”, the entire claim case file or administrative file regardless if the plan is a statutory ERISA plan.
As one of the healthcare providers who attended ERISAclaim.com Seminars complained: “Since we were asked by a payer to pay back for more than $300,000 as alleged overpayment about 2 years ago, we have spent more than $60,000 to $70,000 on attorney fees in a fight over the overpayment demand, at the same time, the payer has put us on pre-payment reviews for all new claims for more than one year without any payment at all.”
ERISA §2560.503-1(f)(2)(iii)(B)
Requires Plan To Make A Timely Decision In 45 Days Accordingly
ERISA §2560.503-1(f)(2)(iii)(B) provides in part: “(f) Timing of notification of benefit determination…….
(B) Post-service claims. In the case of a post-service claim, the plan administrator shall notify the claimant, in accordance with paragraph (g) of this section, of the plan's adverse benefit determination
within a reasonable period of time,
but not later than 30 days after receipt of the claim. This period may be extended one time by the plan for up to 15 days, provided that the plan administrator both determines that such an extension is necessary due to matters beyond the control of the plan and notifies the claimant, prior to the expiration of the initial 30-day period, of the circumstances requiring the extension of time and the date by which the plan expects to render a decision. If such an extension is necessary due to a failure of the claimant to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information, and the claimant shall be afforded at least 45 days from receipt of the notice within which to provide the specified information.” (Emphasis added)
<<http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm>>
DOL FAQs About The Benefit Claims Procedure Regulation
< http://www.dol.gov/ebsa/faqs/faq_claims_proc_reg.html>
“C-3: If the period within which a group health claim must be decided is ending and the claimant has yet to furnish all the information necessary to decide the claim, may the plan extend the time period for deciding the claim and, if so, for how long?
· The date on which a response from the claimant is received by the plan · The date established by the plan for the furnishing of the requested information (at least 45 days) The extension period (15 days) – within which a decision must be made by the plan – will begin to run from the date on which the claimant’s response is received by the plan
(without regard to whether all of the requested information is provided) or, if earlier, the due date established by the plan for furnishing the requested information (at least 45 days). See §§ 2560.503-1(f)(2)(iii) (A) and (B); 2560.503-1(f)(4); 2560.503-1(i)(4). Also see 65 FR at 70250, n.21.” (Emphasis added)
DOL ERISA Claims Guidance: Filing A Claim For Your Health Or Disability Benefits
< http://www.dol.gov/ebsa/publications/filingbenefitsclaim.html>
“Waiting For A Decision On Your Claim
Post-service health claims must be decided within a reasonable period of time, but not later than 30 days after the plan has received the claim. If, because of reasons beyond the plan’s control, more time is needed to review your request, the plan may extend the time period up to an additional 15 days. However, the plan administrator has to let you know before the end of the first 30-day period, explaining the reason for the delay, requesting any additional information needed, and advising you when a final decision is expected. If more information is requested, you have at least 45 days to supply it.
The claim then must be decided no later than 15 days after you supply the additional information or the period of time given by the plan to do so ends, whichever comes first.
The plan needs your consent if it wants more time after its first extension.
The plan must give you notice that your claim has been denied in whole or in part (paying less than 100% of the claim) before the end of the time allotted for the decision. (Emphasis added)
DOL ERISA Claims Guidance: What You Should Know About Filing Your Health Benefits Claim
< http://www.dol.gov/ebsa/publications/wyskfhbc.html>
“Obtain A Copy Of Your Summary Plan Description (Often Referred To As An SPD)
The first step you should take - even before you are ready to file a benefit claim - is to carefully read your plan’s summary plan description.
This is a document which your plan administrator must furnish to you after you join the plan. You can also request a copy from your plan administrator. The SPD gives you a detailed summary of your plan - how it works, what benefits it provides, and how they may be obtained (the process for filing your claim). The summary plan description is also required to describe your rights and protections under ERISA.
Your plan’s claims procedure should state the time within which the plan must provide you with a decision on your claim. Be sure to look for these in your SPD. When you submit a claim to your plan, note the date and keep track of the time as you wait for a decision. Some plans may have different time periods depending on the nature of the benefit claim - such as whether the claim is for urgent care and whether the claim is filed before medical care is received or after. Some plans’ procedures allow the plan to extend the time period. Your plan’s claims procedure should provide for the plan’s notification to you of the plan’s decision on your claim for benefits. If you do not get a response from your plan within the specified time period, contact your plan administrator.” (Emphasis added)
United States Supreme Court unanimously ruled on 06/21/2004 that federal law, ERISA, governs ERISA claim denials and delays and pre-empts any and all state laws.
On January, 26, 2009, a unanimous U.S. Supreme court ruled that ERISA plan administrator must follow ERISA regulation and Plan documents with no exceptions to decide how pre-payment review and timely benefit determination decisions should be made by “the terms of the plan”. ERISA Statutes, 29 U. S. C. §1132(a)(1)(B), a straight for-ward rule that lets employers “ ‘establish a uniform administrative scheme, [with] a set of standard procedures to guide processing of claims and disbursement of benefits in all pre-payment reviews practice. ERISA forecloses any justification for enquiries into expressions of intent from SIU Investigators, SIU of TPA/ASO Medical Policies, and PPO guidelines, in favor of the virtues of adhering to an uncomplicated rule from ERISA as intended by Congress.
""2. Although Liv’s waiver was not nullified by §1056’s express terms, the plan administrator did its ERISA duty by paying the SIP benefits to Liv in conformity with the plan documents. ERISA provides no exception to the plan administrator’s duty to act in accordance with plan documents. Thus, the Estate’s claim stands or falls by “the terms of the plan,”
29 U. S. C. §1132(a)(1)(B), a straight for-ward rule that lets employers “ ‘establish a uniform administrative scheme, [with] a set of standard procedures to guide processing of claims and disbursement of benefits,’ ” Egelhoff v. Egelhoff, 532 U. S. 141, 148. By giving a plan participant a clear set of instructions for making his own instructions clear, ERISA forecloses any justification for enquiries into expressions of intent, in favor of the virtues of adhering to an uncomplicated rule.
Less certain rules could force plan administrators to examine numerous external documents purporting to be waivers and draw them into litigation like this over those waivers’ meaning and enforceability......."
This 2009 U.S. Supreme court unanimous answered our current questions if ERISA pre-empts and invalidates all TPA/ASO, PPO, SIU programs and state laws!
Patient Protection and Affordable Care Act, PPACA §2719, went into effect upon its enactment of the act, on March 23, 2010, after President Barack Obama signed PPACA into law. PPACA §2719 requires every group health plan to comply with the established ERISA appeal process, 29 CFR, §2560.503-1:
`(a) Internal Claims Appeals- `(1) IN GENERAL- A group health plan and a health insurance issuer offering group or individual health insurance coverage shall implement an effective appeals process for appeals of coverage determinations and claims, under which the plan or issuer shall, at a minimum—
`(A) a group health plan and a health insurance issuer offering group health coverage shall provide an internal claims and appeals process that initially
incorporates the claims and appeals procedures (including urgent claims) set forth at section 2560.503-1 of title 29, Code of Federal Regulations, as published on November 21, 2000 (65 Fed. Reg. 70256), and shall update such process in accordance with any standards established by the Secretary of Labor for such plans and issuers; and
< http://thomas.loc.gov/cgi-bin/query/z?c111:H.R.3590.eas:>
Apparently, starting from March 23, 2010,
§2719 (a)(1)(A)(C) of PPACA requires every group health plan and health insurance issuer for individual coverage to “(A) have in effect an internal claims appeal process” and “(C) allow an enrollee to review their file”, the entire claim case file or administrative file regardless if the plan is a statutory ERISA plan.
Strategies for Pre-Payment Review Delays and Denials – Deemed Denial ERISA Appeals Although specific deemed denial appeals are beyond the scope of this article, the actual appeal letter and form for deemed denial are 33 page long, the general strategies are very simple:
No-pay or no-EOB / denial notice after 30-45 days is considered "deemed denial" as provided by ERISA claim regulation;
State Prompt Pay Laws are useless or not applicable for any ERISA plans, both self-insured and full-insured (through purchase of insurance) plans, and as soon as the plan did anything within 30 days, such as pre-payment review notice, prompt pay laws are moot issues;
"Deemed Denial" triggers your ERISA Miranda's Rights, ERISA Full and Fair Review - Appeals Rights, your ERISA Constitutional Rights, to fight back against any fraud and abuse by payers / TPA's as ERISA compliance initiatives;
After 45 days, you should exercise your ERISA Miranda's Rights, file ERISA appeals with the Plan Administrator, to demand for disclosure and compliance from the plan and TPA's. Before the denial, you bear the burden of proof for your claims, after the denial, the plan bears the burden of proof as to why the claims were denied or not decided in a timely compliance fashion;
Once "deemed denied", you are the boss, the reviewer, to review the plan's failure in compliance with ERISA, you must change from defense to offense,
aggressively investigate and report to DOL/FBI any abuse and fraud by TPA's and plan administrators for any ERISA violations.
New ERISA Appeal Books Will provide The Most Powerful Solution to the Pre-Payment Review Denials and Appeals, as a turn-key appeal compliance practice for providers and payers alike.
For any significant dollar size in deemed denials, Dr. Jin Zhou is available for special on-site consulting to assist you with quicker solutions.
For more information on our ERISA Appeal CD Book and Systems, please visit our website: http://www.erisaclaim.com/products.htm
For more information or to arrange an interview, please contact Dr. Jin Zhou, president of ERISAclaim.com at 630-808-723 and ERISAclaim@aol.com or visit: <http://www.erisaclaim.com/products.htm>
New Webinars Announced From ERISAcaim.com To Resuscitate Revenue Cycle Crisis With Right Federal Law Magic. Providers Are Seemingly Left With No Common Remedies In Wake Of Financial Debilitating Overpayment Demand And Recoupment From Payers, An Increasing Number Of Healthcare Providers Are Also Facing Bankrupting Pre-Payment Review Delays For Up To Over A Year Of No-Pays And Real Denials, In An Unprecedented U.S. Healthcare Avatar: No Payment From Insurance Companies But Pay Back To Insurance Companies By Providers. Once Informed Of Pre-Payment Reviews, All State Prompt Pay Laws No Longer Apply. Health Reform for Out-Of-Network Providers: Receiving Insurance Checks Directly? – Free Webinars on Why and How 04/05/2010, Hanover Park, IL
ERISAclaim.com Is Celebrating Its Successful Webinars On New Healthcare Reimbursement Laws, Offered Since The House Passed Its Version Of Sweeping Reform Bill In Last November, And Subsequent Senate Bill With Identical Provisions For Appeals Laws. After President Obama Signed Into Law The Final Bill On March 23, 2010, Healthcare Providers Have Attended Its Daily Webinars With Overwhelming Reactions: Obama Made An Offer We Can’t Refuse, “To Receive Continued Coverage Pending The Outcome Of The Appeals Process”.
New Free Webinars Announced From ERISAclaim.com To Discuss The Latest And The First Federal Court Ruling On March 18, 2010 That A PPO Participating Provider’s Lawsuit Against Anthem BCBS, For The Alleged Wrongful Overpayment Recoupment and Even Withholding From Different Patients, Is Completely Governed By Federal Law, ERISA, Rather Than PPO Contracts And State Laws. The Court Decision Was Mainly Relied Upon U.S. Supreme Court Rulings, the Federal Court Ruling Is Timely Consistent With New Obama Health Reform Laws That Mandate ERISA Appeals For All Group Health Plans And Health Providers. The Federal Court Timely Ruling and New Health Reform Law Mandates Are Vital and Crucial Guidance for a Potentially $6 Trillion Overpayment Market for Every One In Healthcare Delivery System.