1. ERISA provides hospitals with most of powerful protections for this kind of problems and reduce medical malpractice lawsuits, if your claim is health-insurance through employment in private sectors;

2. Under new federal ERISA claim regulation, "urgent care" does not require pre-certification or prior-certification from anyone, it is against the law to impose pre-certification requirements for urgent care;

3. "Urgent care" is determined by attending physicians instead of insurance companies under new claim regulation;

4. Healthcare professionals are considered as authorized representatives by default under ERISA for urgent care claims;

5. Urgent care claims requires 72 hour response time, absolutely better than 30 days, State Law Prompt Pay protections;

6. ERISA written appeal to the claim fiduciary/plan administrator is only protection for hospital reimbursement and a prompt medical care rendered without waiting for pre-certification in urgent cases such as in this one can drastically reduce medical malpractice crisis, ERISA is the main solution, among other things, to medical malpractice crisis in this country;

7. Hospital executives, reimburse managers and medical billers are completely clueless about this new federal claim regulation that went into effect January 01, 2003 for all ERISA plans across the country, 80% of Healthcare claims in this country.

8. American employers and Healthcare executives failed to comply with ERISA in health-insurance/benefits administration, federal government failed to enforce ERISA regulations are the main reasons for American pension crisis, such as Enron and WorldCom, and Healthcare crisis faced by this country today.



1. ERISA provides hospitals with most of powerful protections for this kind of problems and reduce medical malpractice lawsuits, if your claim is health-insurance through employment in private sectors;

Health-insurance through employment in private sectors = ERISA, excluding governmental plans, Medicare/Medicaid, church, workers compensation and personal injury cases,

Sec. 1002. - Definitions



Quote:
For purposes of this subchapter:
(1)

The terms ''employee welfare benefit plan'' and ''welfare plan'' mean any plan, fund, or program which was heretofore or is hereafter established or maintained by an employer or by an employee organization, or by both, to the extent that such plan, fund, or program was established or is maintained for the purpose of providing for its participants or their beneficiaries, through the purchase of insurance or otherwise,



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2. Under new federal ERISA claim regulation, "urgent care" does not require pre-certification or prior-certification from anyone, it is against the law to impose pre-certification requirements for urgent care;

Employee Retirement Income Security Act of 1974; Rules and Regulations for Administration and Enforcement; Claims Procedure; .

Page 70266

Quote:
(3) The claims procedures do not contain any provision, and are not
administered in a way, that unduly inhibits or hampers the initiation
or processing of claims for benefits. For example, a provision or
practice that requires payment of a fee or costs as a condition to
making a claim or to appealing an adverse benefit determination would
be considered to unduly inhibit the initiation and processing of claims
for benefits. Also, the denial of a claim for failure to obtain a prior
approval under circumstances that would make obtaining such prior
approval impossible or where application of the prior approval process
could seriously jeopardize the life or health of the claimant (e.g., in
the case of a group health plan, the claimant is unconscious and in
need of immediate care at the time medical treatment is required) would
constitute a practice that unduly inhibits the initiation and
processing of a claim;


3. "Urgent care" is determined by attending physicians instead of insurance companies under new claim regulation;

Employee Retirement Income Security Act of 1974; Rules and Regulations for Administration and Enforcement; Claims Procedure; .

Page 70271

Quote:
(1)(i) A ``claim involving urgent care'' is any claim for medical
care or treatment with respect to which the application of the time
periods for making non-urgent care determinations--
(A) Could seriously jeopardize the life or health of the claimant
or the ability of the claimant to regain maximum function, or,
(B) In the opinion of a physician with knowledge of the claimant's
medical condition, would subject the claimant to severe pain that
cannot be adequately managed without the care or treatment that is the
subject of the claim.
(ii) Except as provided in paragraph (m)(1)(iii) of this section,
whether a claim is a ``claim involving urgent care'' within the meaning
of paragraph (m)(1)(i)(A) of this section is to be determined by an
individual acting on behalf of the plan applying the judgment of a
prudent layperson who possesses an average knowledge of health and
medicine.
(iii) Any claim that a physician with knowledge of the claimant's
medical condition determines is a ``claim involving urgent care''
within the meaning of paragraph (m)(1)(i) of this section shall be
treated as a ``claim involving urgent care'' for purposes of this
section.



4. Healthcare professionals are considered as authorized representatives by default under ERISA for urgent care claims;

Employee Retirement Income Security Act of 1974; Rules and Regulations for Administration and Enforcement; Claims Procedure; .

Page 70266

Quote:
(4) The claims procedures do not preclude an authorized
representative of a claimant from acting on behalf of such claimant in
pursuing a benefit claim or appeal of an adverse benefit determination.
Nevertheless, a plan may establish reasonable procedures for
determining whether an individual has been authorized to act on behalf
of a claimant, provided that, in the case of a claim involving urgent
care, within the meaning of paragraph (m)(1) of this section, a health
care professional, within the meaning of paragraph (m)(7) of this
section, with knowledge of a claimant's medical condition shall be
permitted to act as the authorized representative of the claimant;



5. Urgent care claims requires 72 hour response time, absolutely better than 30 days, State Law Prompt Pay protections;




USDOL/Pension and Welfare Benefits Administration

Fact Sheet       
Patients’ Rights Claims Procedure Regulation       
U.S. Department of Labor
Pension and Welfare Benefits Administration
November 20, 2000
       
       

Quote:
Faster Decisions        
Faster decisions on initial claims - rather than 90 days (or more) under current regulation, the new rule would require decisions (in most cases) not later than:
72 hours for urgent care claims
15 days for pre-service claims
30 days for post-service claims
One 15 day extension for pre- and post-service claims        

       

6. ERISA written appeal to the claim fiduciary/plan administrator is only protection for hospital reimbursement and a prompt medical care rendered without waiting for pre-certification in urgent cases such as in this one can drastically reduce medical malpractice crisis, ERISA is the main solution, among other things, to medical malpractice crisis in this country;


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7. Hospital executives, reimburse managers and medical billers are completely clueless about this new federal claim regulation that went into effect January 01, 2003 for all ERISA plans across the country, 80% of Healthcare claims in this country.

ERISAclaim.com: What's New? You Must Comply with New Federal Claim Regulations!

ERISAclaim.com: Appeals for Commonly Seen Medical Claim Denials with Superpower from Federal & State Laws


8. American employers and Healthcare executives failed to comply with ERISA in health-insurance/benefits administration, federal government failed to enforce ERISA regulations are the main reasons for American pension crisis, such as Enron and WorldCom, and Healthcare crisis faced by this country today.


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Jin Zhou
ERISAclaim.com