ERISA Appeals


As many as 98% of healthcare providers believe that health plans have the final authority to determine allowed reimbursement, but that assumption is often false. Most commercial and managed care health plans are actually subject to ERISA, which dictates that reimbursement must follow the guidelines outlined in employee benefit plans. Providers may be due millions in additional revenue under ERISA.

Introduction

The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that sets a minimum standard for health plans in private industry to protect the rights of beneficiaries in employer-sponsored programs. By extension, they also protect the healthcare providers who treat those beneficiaries.

Health plans are accustomed to rejecting claims or reducing reimbursement based on their own established rates and policies, or on the rate agreements made with their in-network providers. However, if denials or underpayments conflict with coverages granted in an employer-sponsored benefits plan, the health plan is unknowingly triggering an opportunity for discovery and investigation of the employers’ benefit plan per ERISA.

In those cases, ERISA affords healthcare providers the right to pursue appeals outside of any agreements with health plans.

Solution

The experienced ERISA appeals analysts review your zero balance accounts to uncover inappropriate denials and underpayments. We provide a projected opportunity that we could collect on your behalf, and we partner with your organization to target the optimal areas for recovery.

You need an expert. The ERISA law, rules, regulations, and related guidance span thousands of pages, and ERISA has been amended dozens of times in nearly three decades—with groundbreaking and pervasive legislation such as COBRA. Although it’s a federal law, courts in different jurisdictions may interpret ERISA provisions differently, so a district court in California may have set a precedent that stands in contrast to a district court ruling in Ohio.

Our specialized ERISA analysts are among very few in the country who are qualified to defend adverse benefit determinations under what is one of the most litigated federal healthcare laws. They are prepared to go “toe to toe” with employers, health plans, and attorneys to defend your rights to proper payment allowed under ERISA.

Example Results

  • $1.2 million recovered for a New York hospital that was denied the use of Alloderm for breast reconstruction surgery.
    • The health plan denied 250 claims, asserting Alloderm was “experimental/investigational.” ERISA appeals based on the Women’s Cancer Rights Act, language from the employer’s Summary Plan Description, and the health plan’s own internal policy resulted in full reimbursement.
  • $350,000 recovered for a Wisconsin hospital denied for emergency implantation of a pacemaker
    • The health plan denied the claim as “medically unnecessary,” and a first appeal was denied by an OB/GYN registered nurse. The ERISA appeal cited violations based on the appeal review of a cardiac case by an OB/GYN registered nurse.
  • $1 million recovered for an out-of-network implantable device supplier
    • A health plan denied numerous claims asserting that out-of-network implantable devices were an “excluded/non-covered” service. ERISA appeals efforts reviewed Summary Plan Descriptions from several employers involved—none precluded out-of-network implantable device suppliers from billing for their services.
  • $750,000 recovered both for anesthesia services provided by a CRNA and for the use of Propofol
    • A health plan denied several claims over two years asserting that the CRNA’s services were not covered under a state employer-based plan. The ERISA appeal proved that the Summary Plan Description did not exclude services rendered by a CRNA nor did it exclude Propofol.