What You Need To Know About Out of Network Billing and ERISA Appeals

Anyone who’s read the paperwork that comes with their health insurance policy is no doubt aware of the differences between in network and out of network appointments and procedures. These procedures are routinely complicated and usually end up going through the state-level appeals process before they end up going completely unpaid. Often, the only way for your hospital or clinic to get the commercial health insurance company to pay up is by sending the claim out via the ERISA appeals process.

Defining Out Of Network Claims

This is something that many health providers have a lot of experience with. Out of network care consists of procedures done outside of a person’s health insurance system. In many cases, they end up going out of network only via a recommendation from one of their healthcare providers. For example, if the out of network doctor is the only one able to perform a certain procedure, the patient has little choice in the matter. In other cases, the patient is outside of their home network, such as on vacation in a different state, when an emergency occurs. They have to see a doctor, go to urgent care, or end up in the emergency room of an out of network hospital. No matter the circumstances, the billing process for these claims is quite complicated.

ERISA Appeals

What Does ERISA Have To Do With Out of Network Billing?

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. According to that same article, “Plan administrators are required to provide participants with the Summary Plan Description (SPD), which is an overview of what a plan provides and how it operates. Before the ACA, providers had a legal right to access patients’ SPDs. Since the health law’s implementation, only the patient or patient’s advocate has a legal right to receive the documentation.” 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 Out of Network Billing Process

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.

What Happens After Your Claims Go Unpaid

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.

ERISA Appeals

This Is Where Federal ERISA Appeals Save the Day

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 the 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.


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.