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.
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.
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.