For Aetna ERISA plans there is good cause for appeals for higher reimbursement using ERISA for OON.
For OON they reduce the fee to U&C which is patient responsibility, we then get help of patient and file appeal. Yes I've not lost one appeal yet for full reimbursement. Mostly I appeal the higher surgical fees. I do Mental health for group that is non par with Aetna. Since I have other pediatric clients, many times we see full billed fee after appeal. Pre-billing we usually get a precertificaion done for surgical claims and then we let patient know our fee is $XX more and proceed to tell them of our appeal process and they are very cooperative.
I have done MANY ERISA appeals and not ONE has ever be sent to a CEO. With ERISA appeals it is of the utmost importance to follow the exact appeal process in the patient's SPD. Some plans such as union plans have a board of trustee's who you must send the appeal to, if you send appeal to CEO of the payer it's just getting kicked over to them and they would have a basis for denial if the appeal process is not followed. A patient's SPD will spell out exactly where to send appeal and who to send it to that is Second step in the process. First step is the patient must sign a valid ARF because a standard AOB is insufficient.