What you don't know about ERISA could be costing your practice big bucks If just the mention of Employee Retirement Income Security Act (ERISA) claims makes your head spin, you-re not alone. Many billers think filing an ERISA appeal is complicated and confusing. Part of the confusion about ERISA appeals comes from confusion as to what constitutes an ERISA payer. Your appeals success rate, however, depends on understanding ERISA and ERISA payers. "The reason why billers are unsuccessful with their appeals is because of their lack of knowledge of ERISA," says Steven M. Verno, CMMC, CMMB, NREMTP, professor of medical coding and billing instruction at Everest Uni-versity. With these expert tips under your belt, you can put yourself on the winning side of the appeals process. Start With the Basics of ERISA 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 does not include Medicare or Medicaid carriers. Many misinformed people think that ERISA only applies to self-funded health plans, but that is not true. Specifically, "an ERISA claim is any private-sector employer-sponsored plan," says Jin Zhou, president of the ERISA Claim Institute of America and founder of the
http://www.erisaclaim.com Web site. "For non-Medicare claims, 80-90 percent of the claims will fall under ERISA." You can verify this online at the Department of Labor's Web site at
http://www.dol.gov/dol/topic/health-plans/erisa.htm. Keep in mind: When you-re verifying patient benefits, it's important to note that a patient can have an insurance card from a carrier such as Aetna or UnitedHealthcare, because these companies often underwrite and administer ERISA plans. "When the physician's office calls, for example, UHC, with whom they are participating providers, UHC will confirm the patient's coverage and verify eligibility. However, UHC (and other insurance companies) will often neglect to tell the physician's office that yes, while the patient is covered, it's an ERISA plan and the patient is covered only in an office downtown or within a certain-mile radius from their workplace," says Leslie Johnson, CCS-P, CPC, manager/consultant of Coding & Compliance for DR Management in Fort Wayne, Ind. Follow the SPD Closely Your first step in filing an ERISA claim is to dig into the summary plan description (SPD), which every insured patient receives. An SPD describes the terms of the healthcare contract between the patient and the insurance company. "It tells what services are allowed versus what aren't and where and with whom," Johnson says. The SPD also names the plan's administrator(s), who ultimately reviews any appeals. Getting a copy of the SPD should be your first step, Zhou says. This ensures you know what the plan covers. "The Labor Department even [...]
