REIMBURSEMENT UPDATE: Take Your Patient's Side: 8 Steps to Successful ERISA Appeals

Empower your facility by helping fight patients' battles

Appealing an Employee Retirement Income Security Act (ERISA) claim on behalf of a patient will not only score you reimbursement but will also win your hospital a reputation as a patient advocate - which means more patients and more income.

ERISA is a federal law governing insurance plans that are self-funded or paid for by an employer, including group plans, PPOs and HMOs. ERISA outlines a very specific procedure and timeline for appeals. A surprising number of providers know little or nothing about this legislation, says Quin Buechner, MS, MDiv, CPC, president of ProActive Consultants in Cumberland, Wis.
Since "almost 80 percent of non-Medicare and non-Medicaid claims fall under the jurisdiction of ERISA, having knowledge of this law will help with many of the denials you receive on a daily basis," says Steven Verno, CMBS, compliance director for the Medical Association of Billers in Hollywood, Fla.
Next time you get denied on an ERISA-governed claim, incorporate these tips into your response:
1. Have the patient make your facility his personal representative for insurance purposes, Verno says. If a claim falls under ERISA jurisdiction, the law requires insurers to respond only to appeals from the patient or the patient's personal representative - which often explains why fiscal intermediaries (FIs) "ignore" appeals from a provider.
"A routine assignment-of-benefits form is not a legal document that makes someone a personal representative," Verno says. You need to include a special clause within your assignment-of-benefits form that details how you as a provider will represent the patient in insurance matters. Every patient should sign this clause just in case his claim falls under ERISA, adds Leslie Barlow, CSP, with B&L Specialty Team in Fruita, Colo.
2. Find out the name and address of the plan administrator or plan fiduciary for the payer you wish to file an appeal with. "Sending the letter to anyone else, such as the medical director, is a waste of time," Verno says. "The plan fiduciary's sole responsibility is to make sure the benefit is paid." If you can't find this information, send the letter to the insurer's general address and demand that the letter be forwarded to the plan administrator or plan fiduciary.
3. Request a copy of the summary plan description (SPD) from the plan administrator. "This document tells you everything about the particular plan," Verno says. You should also ask for all the documents that were used to make the adverse benefit determination (ABD), as well as the name and specialty of the physician (working for the FI) who made the ABD. Hint: Anytime a plan under ERISA fails to pay 100 percent [...]

- Published on 2004-10-11