How ERISA Appeals on Medicare Reimbursements Can Help Keep a Hospital’s Doors Open

Medicare reimbursements are big business. These reimbursements, especially those that are on Part B plans that seniors enroll in themselves, can create headaches for hospitals, especially when they lose the ability to accept Medicare in general. This recently happened at a hospital in Ohio, and it might end up becoming one of the first casualties of 2019 unless they can collect on prior appealed reimbursements using Federal ERISA law.

The Role of Medicare in Hospitals

Smaller hospitals, such as Elizabeth Place in Dayton, Ohio, are subject to a number of rules and regulations. According to the law, “a hospital must have two inpatients at the time of a survey. A hospital also must be ‘primarily engaged’in inpatient services, which is determined in part by average daily census and average length-of-stay benchmarks.” CMS has decided that Elizabeth Place doesn’t meet those regulations, so it terminated their ability to accept both Medicare and Medicaid patients. Since over 60% of their patients use either of those types of insurance, Elizabeth Place is in peril. However, there is a solution to help them keep their doors open for a bit longer – Federal ERISA appeals.

The Types of Medicare That You Need to Be Aware Of

There are two main types of Medicare. There are the standard plans, called Medicare Part A that retirees have. These are run by the federal government and pay for many essential healthcare procedures, particularly things like hospital care, hospice, home nursing care, and others. This portion of Medicare is available to retirees and their spouses who have paid into the system. There’s no premium charge for Part A. The others are the Medicare Advantage plans, also known as Plan B. These are run through a commercial insurance company. There’s a premium involved, but they cover additional health care expenses, like dental, eye care, prescription drugs, doctor visits, and more. When problems arise with Medicare reimbursements, they are usually through Part B coverage.

Collecting on Medicare Reimbursements

The process for collection on Medicare Advantage plan claims is similar to those of standard commercial health insurance claims. Your hospital or clinic has a contract with these companies that govern everything from the amounts that are paid to the specific codes that are used. When those amounts or codes are wrong (which happens quite a bit, as the contracts and billing processes change often) the claims end up being underpaid or unpaid. These Medicare reimbursements then turn into a bit of a headache for your billing employees.

Every claim receives a maximum of three state-level appeals, even if the claim is run through a Medicare Advantage plan. This is how the process usually works: your billing employee looks at the charge, notes the patient’s name, identifying information, and commercial insurance company, and then matches the procedure with the codes and amounts allowed by that insurance company. They submit the claim. It ends up being partially paid, so it’s submitted yet again. This repeats until the three state-level appeals are exhausted. At this point, the Medicare reimbursements cease.

How to Handle Appealed Medicare Reimbursements

The appeals, as you can imagine, take up quite a bit of time and money. These are usually handled by your billing employees, who need to be able to juggle filing current claims with refiling those unpaid and underpaid Medicare reimbursements. Every time one of these claims is sent back, your employees need to double check many things, including the amounts, the coding, and even whether or not preauthorization was needed and obtained. They also need to double check to ensure that the claim was filed with the correct commercial health insurance company. The effort needed to do all of this and then send that claim back for payment takes up precious time that those employees could be using to handle other tasks.

Even worse, once those three state-level appeals are reached, your hospital or clinic is usually out of luck. Those claims just pile up, despite the fact that you need to pay your employees (the billing department especially), all of your utilities, routine maintenance expenses, and even the costs of supplies and equipment. This is what leads many hospitals and clinics to bankruptcy.

There is little that can be done when the amount of debt that you’re carrying exceeds the positive cash flow that you need in order to keep running. Those Medicare reimbursements end up on the wrong side of the balance sheet. We like to call that a “debt bucket.” When the bucket is full, you can’t pay your bills. Clearly, this is a problem – one with a great solution. The solution to your debt problem is the Federal ERISA process.

Using Federal ERISA Laws to Your Advantage

The Federal ERISA process is your best bet on getting those unpaid and underpaid Medicare reimbursements paid. ERISA stands for the Employee Retirement Income Security Act. This federal act, which was put into place back in the 1970s, was initially intended to protect and regulate employee retirement plans. However, it’s purpose has expanded over the years. It now includes many other provisions, one of which regulates self-funded health insurance plans. These plans are the ones that employees pay into with every paycheck. Since Medicare Advantage plans are considered to be self-funded, as the retirees pay extra for them, they fall under Federal ERISA laws.

The main issue here is the fact that many hospitals and clinic billing personnel don’t know how to file these Medicare reimbursement claims with the people in charge of ensuring that Federal ERISA laws are adhered to. This isn’t taught in the standard medical billing and coding training courses. There are two reasons for this. One, it’s a very specialized process that takes some time and care to follow. And two, the law is fairly obscure. It isn’t even taught in many law degree programs. On top of this, those employees are too busy trying to keep up with current claims and those that are still under state appeals. They just don’t have to the time to add another pile of claims to file to their already full plates.

In order to successfully file those Federal ERISA appeals, you need to hire a company that specializes in them. Companies like us, ERISA Recovery, are experts in this process. We know how to file those claims and follow up with the commercial insurance companies to ensure that you get those funds. This is the best solution to all of the headaches that come with unpaid and underpaid Medicare reimbursements.      

Taking Those Next Steps

It’s time for you to make a decision. You can either allow your hospital or clinic to sit on those Medicare reimbursements and place them in the bad debt bucket, or you can hire ERISA Recovery in order to clear up those unpaid and underpaid claims. We’re experts in the Federal ERISA process and have a guarantee in place – we’ll get you $1,000,000 in those claims within a 12 month period – as long as we can get all of the paperwork that we need from you. Even better, we won’t charge you up front for our services. We think you’re ready, so call us today. You can reach one of our Federal ERISA experts at (972) 331-4140. We also have a contact form on our website. Just fill it out, and one of our experts will give you a call.