It’s happened again. Another hospital is on the brink of financial disaster. However, this one, instead of closing its doors entirely, is planning on cutting services and jobs. The administrators of this hospital hope that by doing this, they can salvage enough of the company in order to keep the doors open, not disappointing and disenfranchising the residents of the area. Sometimes, this works, but in others, more drastic measures are needed to prevent the hospital from going under. However, none of this would be necessary if the hospital administrators used the Federal ERISA Act in order to collect on unpaid and underpaid commercial healthcare claims.
What Federal ERISA Act Does
When the Federal ERISA Act was originally signed into place back in the 1970s, they were designed to protect employee pension plans. More specifically, they protected the types of pension plans that people – employees, to be precise – paid into. Over time, this was expanded to include commercial health insurance policies as well, and like the original purpose of the law, it covers the plans that employees pay into. Every time that you pay for your employee health insurance plan out of your paycheck, it becomes eligible for protection under this Act. This is why Medicare Part D falls under the protections as well since people pay into them. They’re a bit more than the average Medicare.
One of the best things about the Federal ERISA Act is that when appeals are filed properly under it, the commercial healthcare insurance companies must pay the claims that they’ve sent through the appeals process. This covers underpayments as well. Basically, as long as the claims meet the following criteria, it’s eligible for collection under ERISA:
1) It involves a commercial health insurance company.
There are some private plans out there that just don’t fall under ERISA. However, many of the commercial health insurance company plans, including the ones from the large companies like Blue Cross/Blue Shield, Aetna, United Healthcare, and more, all qualify.
2) The claim must have exhausted its standard appeals.
Typically, every claim submitted from a hospital or clinic is allowed a certain amount of state-level appeal. The magic number here is three. This means that the clinic must submit the claim, have it sent back unpaid, and then repeat this process upwards of three times. Underpaid claims are eligible for these state appeals as well. Once those three are exhausted, nothing more can be done with the claim until it gets sent off for an ERISA appeal.
3) The plan must be one that an employee paid into.
If the employee doesn’t pay any of their health insurance costs, and every penny of that insurance is covered by the employer, then it may not qualify for an ERISA appeal. Thankfully, for the sake of the hospitals and clinics, these types of plans are very rare and are usually given out by the government to federal employees or to members of a union. On the other hand, if the employee pays for some of the insurance costs – no matter how much – the plan falls under ERISA and is eligible for these appeals.
Filing a Federal ERISA Appeal
This is the tricky part of the process. Once those claims have gone through the state level appeals and remain unpaid, they usually end up on the wrong side of the hospital’s balance sheet. When enough of them exist and they begin to add up, it’s not unusual to have so many that the hospital ends up in financial danger. At that point, they end up doing what the hospital in the main example did and begin cutting costs. In many cases, the administrators never thing to go the Federal ERISA appeal route. Why? The short answer is that many of them simply don’t know about it.
How can they not know about it? Well, the Federal ERISA Act isn’t covered by most law schools, despite the fact that it’s a landmark act that changed a lot of protections for workers. It just isn’t taught, so it makes sense that the administrators of hospitals wouldn’t know about it. In addition to this, most of the hospital’s billing employees have never heard of it either. Plus, they wouldn’t be able to file an appeal even if they had the time. This particular appeal is complicated and they are very busy.
Hospital Billing Offices
Many hospitals, and even some large clinics that are part of a hospital network or chain have a special billing department. These employees have very specialized training. They know how to read and understand the codes of patient charts. Those charts include details on the patients, their doctors, and every procedure that they had completed. All of that information is needed when the procedure is billed out. The charts are turned into codes, which are then matched up with the chargemaster document. Every hospital or a large network of providers has one of these. It contains the billing codes and rates that the administrators have negotiated with the commercial health insurance companies. Everything is billed out based on those rates. If that document isn’t kept updated, then things are billed wrong and those claims end up underpaid or sent out for appeals.
However, even if the rates are correct, this doesn’t mean that the claim will get paid by the commercial health insurance company. In a perfect world, it would, but the world isn’t perfect. Many of the unpaid and appealed claims involve simple mistakes, like the misspelling of names or the mislabeling of insurance codes. Sometimes, the wrong amounts are billed. No one is perfect and mistakes are made. As long as there are dedicated employees in the billing department who can go through these unpaid claims and correct them before sending them back on appeal, things don’t fall apart, and in some cases, those claims do get paid.
But what happens if they don’t? This is where the Federal ERISA Act comes in. According to it, those claims that were sent out to the commercial health insurance companies must be paid. The law says so. It’s just a matter of gathering those claims and then sending them to a company that understands how to handle these specific appeals.
What We Do
This is where we come in. Our company has dozens of employees who are trained in every aspect of the Federal ERISA appeals process. All that we need is some basic information from you, and then we can get started. Since this is all that our employees do, they are experts in the field and know just how to make those commercial health insurance companies pay up. You reach out to us, we contact you, and then we get started. It’s that simple. If you want to keep your hospital or clinic in the black instead of the red, then you need to go through your unpaid claims and get them sent out for these Federal ERISA Appeals. There are hundreds of people relying on you, including your employees and your patients. They need you to keep those doors open and not cut services, let go of workers and go under. This can be prevented if you contact us today.