Medical Billing Forum

Payments => Insurance Payments => Topic started by: CJM on October 26, 2009, 04:05:00 PM

Title: Self-funded insurance
Post by: CJM on October 26, 2009, 04:05:00 PM
When a self-funded insurance company (such as a Labor Group) is not paying, is there anyone to complain to?  Or any way to appeal a claim they are refusing to pay?  The Illinois Insurance Commissioner has no jurisdiction over them.
Title: Re: Self-funded insurance
Post by: Michele on October 26, 2009, 06:24:30 PM
We have had similar problems and I'm not aware of any other course of action you have.  I'm not fond of self funded carriers.

Title: Re: Self-funded insurance
Post by: PMRNC on October 26, 2009, 08:07:59 PM
I feel opposite. I've had union insurance all my life (father then husband) and I have NEVER had problems. What kind of denials are you getting? There are many ways to fight ERISA policies.. but of course it depends on what your fighting. If it's a policy provision you will have a tough time. I found going right to the administrator worked very well for small types of denials or U&C cuts.. with self funded plans (ERISA) the administrator has power to enforce or overturn certain provisions. Let us know what type of denials you are dealing with.
Title: Re: Self-funded insurance
Post by: CJM on November 11, 2009, 02:41:00 PM
Thanks for the replies!  As far as the types of denials, mostly they are because of medical necessity.  One policy allowed the patient 24 visits, but now they are saying they will only pay for 20 visits (after he has had the 24).  Another is claiming the soap notes don't show enough improvement.  I've filed appeals, but they aren't changing their decisions.  I was just wondering if there was anything else I could do.
Again, thanks for the answers to my posts!
Title: Re: Self-funded insurance
Post by: PMRNC on November 11, 2009, 06:27:48 PM
I rarely get denials on my own coverage which is through Union, but there is a procedure set in place that we can call the plan administrator and they actually will handle it if it's something that can be appealed. Get the patient involved would be your best bet. If you can, bill the patient and let patient call the plan administrator. If there are plan provisions such as set amounts of visits written in the policy chances are you won't get that paid, however if it's not a plan provision and they are administratively only allowing a set amount, then the patient might be able to get additional visits. It really depends on the policy. Here is a website with a lot of good Information on ERISA If you can get past the really bad website design and flashing text, there is some good information there.
Title: Re: Self-funded insurance
Post by: CJM on November 18, 2009, 01:46:56 PM
Thanks for the info and the site - I'll check it out!
Title: Re: Self-funded insurance
Post by: Steve Verno CMBS, CEMCS on November 30, 2009, 01:54:34 PM
Self funded plans are under the jurisdiction of ERISA per
29 USC 18, 1003(a).

The patient has all the rights under 29 CFR 2560.503-1

You can represent the patient with their written permission. 

Complaints can be made to the Department of Labor's enforcement agency, the EBSA.

The DOL FAQ can be found here: