Getting to Know the Provisions under ERISA

by | Published on Sep 18, 2013 | Medical Billing

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What is ERISA?

ERISA is something your practice needs to know about. ERISA, or Employee Retirement Income Security Act, is a 1974-enacted Federal Law conceived to protect the pension plan of an employee. However the law went beyond its initial scope since employers began adding health insurance as one of the benefits of employment. Health benefit plans were therefore protected under ERISA.

The ERISA law has total jurisdiction over the process of claims and the health benefit payments as well as an improperly paid or denied health benefit’s appeals process. In fact, any health benefit provided by an employer involved in functioning for commercial benefit comes under the jurisdiction of ERISA. However, health benefits provided by Federal, State, City or County employers, broadly classified as government employers, or Church employers such as hospitals or other institutions do not come under the jurisdiction of ERISA.

Who Has the Right for Claims Appeal and Denial under ERISA?

A patient’s legal representative or the patient himself/herself has the right for submitting a claim or appealing a denial. The service provider or the medical biller of the provider has no right in submitting a claim or appealing a denial or underpayment. Medical billers and providers do not have any rights or provisions under ERISA.

The Provision of the ERISA

The ERISA law is a provision against the notion among providers and medical billers that when services are provided to a patient and a claim is sent to the insurance company, the provider owns the claim and that it has to be paid by the insurance company. Only the patient has the right to claim payment of the health benefits. The health insurance company’s determination of benefits can be appealed by the patient. Legal action can only be settled federally after the exhaustion of the appeals process for determining a health benefit.

An experienced medical billing and coding company will have a clear picture about ERISA and its provisions and can guide your physician practice through the seemingly grey areas.

Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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