ERISA Appeals Revenue Recovery Service
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.
Would you like to achieve any of the following?
- 1% increase in net patient service revenue
- Reduced denials and underpayments
- Increased revenue recovery from zero balance accounts
- Improved patient satisfaction from increased insurance coverage reducing patient liabilities
- Tapping a revenue source not currently addressed by any of your PFS representatives or revenue cycle vendors
If so, Argos Health can definitely help.
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 at Argos Health review your zero balance accounts to uncover inappropriate denials and underpayments.
We provide a projected opportunity that Argos Health 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.
$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.
The Argos Advantage
Argos Health is the industry’s most experienced complex claims vendor, ranked No. 1 in Black Book and named a KLAS top performer.
Our ERISA appeals service is contingency-based and completely turnkey for providers. We manage only zero balance accounts that are fully adjudicated, so our work does not conflict with other revenue recovery efforts. Our simple data-transfer process to identify claims is virtually effortless for your staff.
Argos Health stands by you to ensure you are insulated from pandemic- related adverse coverage decisions, as well as timely filing and appeal deadline rules that have been impacted by Disaster Relief Notice 518 for ERISA-governed health plans.
You must have questions. Please click here to request a call-back for more information from one of our experts. We look forward to sharing more information.
ERISA Appeals White Paper
Revenue Recovery with ERISA Appeals: Exploring the Untapped Potential in Denials and Underpayments
ERISA affords healthcare providers the right to pursue appeals outside of any agreements with health plans, and the opportunity for additional revenue may be substantial.
The white paper covers the following topics:
- A background on ERISA and its complexities
- Why ERISA appeals are underutilized in the hospital revenue cycle
- Which plans are covered by ERISA
- How ERISA benefit plans are managed
- The role of TPAs under ERISA
- Which adverse benefit determinations are appealable under ERISA
- A comparison of an ERISA appeal vs. a traditional denial appeal
- And more…
Download our white paper to learn why providers could see a 1% increase in net patient service revenue by taking advantage of ERISA appeals.
Click here to download our ERISA revenue recovery service sales sheet.
What does it cost to get started with your service?
We have no implementation fees or startup costs, and our work is performed on a contingency basis.
Do you require a client to provide a minimum volume of claims?
We have no minimum claim volume or client size requirements.
Does it matter whether we are an in-network or out-of-network provider?
We manage ERISA appeals in either situation. ERISA laws normally supersede any contract you may have as an in-network provider, but we respect the relationships our in-network clients have with their health plans.
We’re a large health system. Is this something we can do in-house?
ERISA work is highly specialized. ERISA claims are exceedingly time-consuming and require considerable expertise to acquire the necessary documentation and file the appropriate paperwork. Very few people in the country are qualified to handle ERISA appeals.