Employer Health Plan Accountability
Witnesses: Frederick D. Hunt, Jr., President, Society of Professional Benefit Administrators, Chevy Chase, MD; Jane F. Greenman, Deputy General Counsel, Human Resources, Allied Signal Corp. Inc., on behalf of the ERISA Industry Committee, Wash., DC; Larry Atkins, President, Health Policy Analysts, Inc., on behalf of the Corporate Health Care Coalition, Wash., DC; & Timothy T. Flaherty, M.D., Secretary-Treasurer, American Medical Association.
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AlliedSignal AMERICAN MEDICAL ASSOCIATION Andrews appeals process Atkins Ballenger benefit claims benefit request beta blockers CAROLYN McCARTHY Chairman Boehner claimant claims procedure Committee on Education companies Congress cost courts coverage decisions definition of medical denial denied Department of Labor Department's doctor employee benefit plans Employer Health Plan EMPLOYER-EMPLOYEE RELATIONS ensure ERISA INDUSTRY COMMITTEE ERISA plans ERISA requires evidence-based medicine external appeals external review federal Flaherty going Greenman health benefits Health Plan Accountability health plan liability healthcare Hearing on Employer HIPAA hospital Hunt hysterectomy issue JOHN BOEHNER LARRY ATKINS Laughter litigation managed managed care medical decisions medical malpractice medical necessity decisions medically necessary Medicare named fiduciary NCQA participants and beneficiaries payer plans percent plan administrator plan fiduciaries plan participants plan's problems proposed regulation punitive damages responsibility review process rules standard of review SUBCOMMITTEE ON EMPLOYER-EMPLOYEE things treating physician Workforce
Page 112 - B for any expenses incurred for items or services — (1) which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member...
Page 109 - Subject to sections 403 (c) and (d), 4042, and 4044, a fiduciary shall discharge his duties with respect to a plan solely in the interest of the participants and beneficiaries and — (A) for the exclusive purpose of: (i) providing benefits to participants and their beneficiaries; and (ii) defraying reasonable expenses of administering the plan...
Page 109 - ... the procedures to be followed in presenting claims for benefits under the plan and the remedies available under the plan for the redress of claims which are denied in whole or in part.
Page 109 - ... written in a manner calculated to be understood by the average plan participant...
Page 95 - New York State Conference of Blue Cross & Blue Shield Plans v. Travelers Ins. Co., 514 US 645, 115 S.Ct.
Page 110 - Secretary, every employee benefit plan shall — (1) provide adequate notice in writing to any participant or beneficiary whose claim for benefits under the plan has been denied, setting forth the specific reasons for such denial, written in a manner calculated to be understood by the participant...
Page 105 - Coalition is an alliance of 25 companies formed in 1993 to reflect the views of large, multi-state, self-insured companies on national health care policy. Coalition members operate health benefit plans for employees and their families as well as retirees, covering over 6 million lives and providing over $12 billion in benefits annually. They have been in the forefront of efforts to provide high quality and cost-effective benefits for employees. Coalition members have extensive experience in designing,...
Page 110 - Under the conference agreement every employee benefit plan is required to provide adequate notice in writing to any participant or beneficiary whose claim for benefits under the plan has been denied, setting forth the specific reasons for denial written in a manner calculated to be understood by the participant.
Page 79 - ERISA has permitted employers to drive major innovations in the Nation's health care system. In partnership with health care providers, employers have worked to collect and analyze health care data, to develop coordinated systems of care for employees and their families, and to develop practice guidelines and protocols to assure mat employees and their families receive high-quality health care, delivered effectively and efficiently.