Thank you both so very much. The Erisa question is one I posed to "specialty attorneys" and they told me it didn't matter if it was related to an audit ( which, you are correct, what they state ). I thought that sounded like they might not know the answer since it was lacking in detail, but how could I say otherwise. Is there a link or somewhere I can find this info? Maybe a reliable site with ERISA info for providers? Again, thank you SO much
If again, these are "group health plans" and not church or govt/state plans, they are indeed protected under ERISA which is a federal law. With ERISA those claims belong to the patient, they do not belong to the provider at all. Basically you send them a letter and reference 29 CFR 2560-503-1 Do a CC to the policy holder because they can bring it to their employer for possible
federal review by the Department of Labor and EBSA. I would reccomend getting the ERISA book from Don Self, it is excellent and NO medical biller should be without it. It's on his website at
www.donself.com Since I learned ERISA from him years ago I've never had to have any of my clients send ONE red dime on a recoupment for ANY reason! If they took the money from additional claims, ERISA worked to get that money back as well (using different type of appeal) The actual reference to that one law 29 CFR 2560-503-1.. .MEMORIZE it. When I did my first few claims I was including verbiage from that law directly and what I found was I didn't have to. You can even look up cases and reference those with the parties and date of ruling only and it will work. Now Don's book will suggest sending the letter to the CEO of the carrier but I've so far not had to do that one time. I send it as an appeal to the carrier and I make sure it's sent certified and I reference the time they have to respond (just like they do) YES you may get angry call from patient, but if you find out that the carrier has not notified the patient of this money being due, let them know they can take this to their employer and ERISA can be used to litigate this because the patient has not been informed.
MAKE sure these plans are not govt payer plans (Medicare, Medicaid, Tricare) or state/federal plans or any type of church plan..then you have ERISA. ERISA trumps state law so when you KNOW it's ERISA, state law goes out the window. Don't even bother.
On Don's website he also has some webinars that are extremely informative. The book has sample appeal letters to use as well.
Once I learned ERISA I dug my heels in because I have challenged my own health policy many many times and WON..even when I was told something was covered but they later denied even referencing where it was stated that it wasn't covered based souly on them telling me it was!
I learned ERISA and it's been a big revenue boost to my clients. I also run PMRNC where we have two medical billing certifications and I'm currently getting ready to put out another JUST for ERISA. When a medical biller knows and utilizes ERiSA you become very valuable to your client or employer.