ERISA and Out of Network Billing Is in the News Again – Here’s What You Need to Know

Out of network billing is a huge issue for hospitals and clinics, because of the complications involved in the process. A recent law was signed into place in New Jersey that changed the laws for consumers who are charged these out of network prices when they receive medical care from a provider who is not usually covered by their commercial health insurance company. The issue here is that while the law helps the average consumer, it does nothing for the hospitals and clinics who could be stuck with dozens of unpaid out of network claims on their end.

The Law and Out of Network Claims

These claims discussed in this recent law come from medical facilities that are considered to be out of the network by commercial health insurance companies. In some cases, the patient receives permission from the company in order to see that medical provider, but this does not help the hospital or clinic who must figure out how to bill the procedure and then wait for their claims to be paid.

In order to make things even more difficult for those hospitals, “the new bill, which excludes self-funded health plans governed by federal ERISA law, also calls on the New Jersey Department of Insurance and Banking to better define “inadvertent” out-of-network care, according to the report.” This is very problematic because if the claims go unpaid long enough, they could end up sending the hospital into bankruptcy. In many cases, their only method of collecting on these claims is through the Federal ERISA process.

ERISA And Out of Network Building Have Some Commonalities

According to an article in Becker’s ASC Review, the “Employee Retirement Income Security Act of 1974 offered providers a straightforward path for success in the OON [out of network] claims and appeals process.” The problem with this is the fact that thanks to the Affordable Care Act, more paperwork is involved. Thanks to a change that took place in January of this year, providers and their billing employees no longer have access to the patient’s Summary Plan Description (SPD), making it difficult to know whether or not the procedure took place out of network or even how to appropriately bill the commercial insurance agency for the claim once they determine that it did. This makes it much more likely that the claim will go unpaid, and eventually end up in the hands of a specialty company that handles Federal ERISA appeals.

The Issue With Out of Network Billing

Hospitals and clinics tend to go through a lengthy appeals process on the state level, especially if they’re dealing with out of network claims. Here’s how the system works in general: The patients have procedures done or meet with doctors.  Some of these are standard checkup appointments, others are outpatient procedures, and still, others necessitate a hospital stay of some kind. The hospital billing employees go through everything that transpired in order to determine the correct billing codes and amounts. If the procedure was out of network, this is even harder to determine. The assigned codes depend solely on the doctors, the procedures, the care involved, and any medications that are prescribed. These coded bills – now called claims – are sent out the commercial insurance companies. The company that they are sent to depends on who that patient’s insurer is. This sounds easy, right?

At their end of things, the commercial insurance company has a process that they go through in order to pay those claims. In some cases, they’ll pay a portion of it or reject it outright. If the claim was out of network, it’s more likely to be completely rejected. The hospital’s billing staff has the ability to appeal these unpaid and rejected claims at the state level. They can do this three times. The problem is that’s a lot of paperwork to have to deal with in a tight time frame, which is exacerbated even more by the fact that the claim is for an out of network procedure.

Unpaid Claims Can Add Up Quickly

In the end, if your clinic or hospital gets lucky, some, or at least a portion of those claims will get paid. If you aren’t lucky, those claims will go and forth for the allotted time frame and end up being completely unpaid. The reasons for this can vary and depend on many different things, including billing codes, pre-approvals (which are hard to come by for out of network procedures), and what the commercial insurance company thinks should be covered or paid for.

After those three state-level appeals are exhausted, your hospital could file Federal ERISA appeals on all of those unpaid or underpaid claims. The problem with this is that your billing staff doesn’t know how to do this, nor do they have the time. The process is complex, and most billing departments are busy either with sending out current bills or wading through state-level appeals. In most cases, those unpaid and underpaid out of network claims end up getting written off.

What The Federal ERISA Law Does

The Federal ERISA appeals process is designed to get your clinic and hospital the money that it’s owed from those commercial insurance companies, even for out of network care. The process works in a very simple way. Rather than letting those claims sit around or having your accountant write them off, organize them into a file and then contact a company that specializes in these types of Federal ERISA appeals. ERISA Recovery is one such company. We know what we’re doing and have knowledgeable staff on hand to deal with the Federal ERISA appeals process. In the beginning, all that we will need from you is a list of those claims and some other information. From there, our trained employees file the appeals and will get you that money. At some point, we might need some additional information, but that all depends on the claims and the Federal ERISA appeals that pertain to them.

The best part? We guarantee that we’ll recover at least one million dollars in denied claims within 12 months, and we don’t charge anything for this service up front. We don’t get paid unless you do – we work on a contingency basis. This gives you a great option to choose. Instead of having those claims end up on the wrong side of your hospital or clinic’s balance sheet, you’ll find it in your bank account. We know how tricky it can be to recover these out of network claims and things have been made even more complicated by the January 2018 decision.

You Need Our Help

Now that you understand the difficulties of billing out of network claims and how useful the Federal ERISA appeals process is, it’s time to make a decision. You can either let those out of the network claims pile up or lead to possible financial ruin, or you can call us. We can get you that money. All that you need to do is call us today at (972) 331-4140. You can also fill out the contact form on our website. It’s time for you to make that choice.