While providers are exceedingly familiar with the traditional payer-based process for appealing claim denials, remarkably few know about ERISA appeals. The Employment Retirement Income Security Act of 1974 (ERISA) gives providers a federal avenue to pursue additional reimbursement—and it picks up where the traditional appeals process leaves off.
Designed to protect the rights of beneficiaries in employer-sponsored programs, ERISA dictates that reimbursement must follow the guidelines outlined in employee benefit plans. As such, ERISA appeals are based on the coverages promised in employer benefit plan documents. If services provided differ from those promised in an employer’s Summary Plan Description (SPD), ERISA grants providers the right to appeal.
Leveraging the Adverse Benefit Determination
The heart of the ERISA appeals process is the Adverse Benefit Determination, which is any decision by the payer that involves a denial, reduction, or termination of benefits.
Adverse Benefit Determinations are not your typical denials. Traditional appeals are based on the contract between the provider and payer. State law presides over these appeals, and the system generally favors the payer. ERISA appeals, conversely, are based on the ERISA law, U.S. Department of Labor guidelines, and supporting case rulings. The prevailing document under discussion is the SPD, not the payer-provider contract, and as a federal law, ERISA supersedes state law.
10 Revenue Recovery Opportunities
The top 10 Adverse Benefit Determinations are the first places to look for ERISA appeals opportunities. In determining revenue recovery opportunities for clients, we start by aggregating the AR represented in claims denied for the following reasons:
- Medical Necessity
- Preauthorization/Precertification – both ER and regular admissions
- Excluded/Not Covered service
- Missing Admission Type when Admission Date is Present
- Maximum allowable exceeded
- ER/Urgent care charges not qualified (different form of medical necessity)
- Timely Filing, Appeal rights exhausted
- Reductions due to not following plan instructions
- Usual, customary, and reasonable
Viewed through this lens, many providers will find millions in recoverable revenue from claims that were inappropriately denied per ERISA.
The Appeals Process
If the denials aren’t the same, neither is the appeals process. While traditional appeals are typically based on payer processes, forms, and filing deadlines, ERISA appeals involve health plan research, communication with employers, potential legal resource involvement, and intimate familiarity with ERISA regulations. ERISA appeals usually take many more steps than the denials with which most healthcare providers are familiar.
ERISA attorneys and appeals specialists understand how to obtain Summary Plan Descriptions and other critical resources. They are prepared to go toe-to-toe with employers, health plans, and attorneys to defend providers’ rights to proper reimbursement allowed under ERISA.
If this is new to you, you’re not alone. Our discussions with providers indicate that no more than 2 or 3 percent are familiar with the ERISA appeals process for revenue recovery. If you’re ready to learn more, we answer providers’ frequently asked questions in the blog post at this link. You can also click here to download our latest white paper, “Revenue Recovery with ERISA Appeals: Exploring the Untapped Potential in Denials and Underpayments.”
Argos Health is a KLAS top performer and offers the broadest range of complex claims services of any vendor in the category. Learn more about our ERISA appeals services by going here.