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ERISA & Overpayment Disputes

From: ERISAclaim.com

 HI, Traci:
 
These are the basic ideas on this overpayment subject:
 
1. If the original payor of the alleged overpayment is from an employer sponsored health plan in private sector, the Federal law, ERISA, governs all of your money dispute and recoupment /withholding, while Medicare, Tricare, FEBHP or all other applicable federal and state laws govern other applicable claims. >80% of non-Medicare claims are ERISA claims in USA;
 
2. If there was an alleged criminal fraud or act, both federal and state laws against criminal act will control, and only government has power to initiate such proceddings;
 
3. All managed care contracts, PPO or HMO, have a legal disclaimer that the plan document, SPD, or Certificate of Coverage, control benefits or coverage dispute (overpayment), while overpayment = any payment more than you billed (>100% claimed) or never claimed, any dispute < you billed is an "revised initial adverse determination", ERISA has the same definition, retrospective benefits denial,  as Medicare on Overpayment. The same is true for almost all other claims, Tricare, FEBHP/OPM, Medicaid, and all others.
 

Medicare Claims Processing Manual, Chapter 29 - Appeals of Claims Decisions

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A post-payment review of an initial determination that results in an overpayment determination constitutes a revised initial determination

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4. If there is a denial, that would trigger an appeal process under applicable laws and regulation as well as plan appeal procedures, for ERISA and from DOL:
Filing A Claim For Your Health Or Disability Benefits
http:
 
For a pdf copy:
 
http:
 
And an earlier version:
 
What You Should Know about Filing Your Health Benefits Claim (Claims Card)

http:

"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 plans 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."

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5. Under ERISA, a claimant has at least 180 days to appeal, this can not be controlled by any MCO contracts;
 
6. Any and ALL state laws and PPO/HMO contracts relating to ERISA money dispute are completely 100% pre-empted, invalidated by ERISA, according to U.S. Supreme Court unanimous ruling in Aetna v. Davila on 06/21/2004:

Aetna Health Inc. v. Davila, 06/21/04, Opinion of the Court

"Held: Respondents state causes of action fall within ERISA502(a)(1)(B), and are therefore completely pre-empted by ERISA 502 and removable to federal court. Pp. 420.

""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 proceedingsconsistent with this opinion.7 It is so ordered."

7.  ERISA, as interpreted U.S. Supreme Court, is your best and most powerful legal protection for your money dispute, but least loved by healthcare providers in USA;
 
8. Current and future overpayment denials and recoupment will wipe out up to 1/3 of providers' income in the next a few years in USA, but >90% providers are happy to simply pay back $ millions so that they don't have to appeal or talk about ERISA, a sad but truthful reality;
 
9. ERISA law is a statutorily prescribed, the Congress ordered, and mandatory /no choice governing laws for overpayment or any money dispute with employer sponsored health plan in private sector in USA for 34 years, ERISA is not a trial of personal fantasy, scam, or some one invented tricks.
 
It is like that if we have a divorce trouble, we go to divorce court under divorce laws, a traffic problem, to traffic court under traffic laws, tax nightmare, to tax court under tax code, then ERISA claim/our current claim trouble, to ERISA court under ERISA laws.
 
WE do all but ERISA laws, we are all happy to be on losing end as long as we don't have to deal with ERISA.
 
10. I have heard >100 times from so many that "we won't do ERISA because we don't like ERISA and unless you can show me ERISA works for us". Think about not knowing and doing divorce, traffic, and tax laws, what would happen to your disputes?
 
ERISA is not about choice, it is about that knowledge is the power, the more and better you know about ERISA, the more you won, because ERISA is not an option or personal choice, it is the governing laws about your money and life.
 
< than 10% of the national overpayments dispute are based upon coding and billing, >90% of them are based on ERISA, Medicare, Tricare and FEHB claim regulations.
 
Nationwide, the providers side is losing terribly in this overpayment money fight, still in dark and clueless, and in suicidal denial stage of the existence of overpayment nightmares, new way of the denial and reversed prompt pay denial.
 
Don and I have tried for more than 5-6 years to train and educate people on this board, so far, ERISA is not loved by office managers, because the most either think ERISA is too hard for us (ERISA is only 6 pages long), or dismissed as irrelevant for our money dispute.
 
ERISA is the Rule of the Money Games, managed care is the sleeping pills for losers, taking a lot of sleeping pills and remain to be clueless on the rule of the game, we are bound to fail again and again,
 
Even worse, many won't even take or like this "awaking up" pill for this reality, Federal law for your money and future, ERISA.
 
11. Every claim denial is different from others, it is beyond this message board and email to cover every types of overpayment appeals;
 
 
Jin
 
 
Jin Zhou
President
www.ERISAclaim.com
ERISA Claim Institute of America
1260 Bamberg Ct.
Hanover Park, IL 60133
630-736-2974