Vital Points to Remember Regarding ERISA

by | Last updated Dec 15, 2023 | Published on Nov 9, 2013 | Medical Coding

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Physicians and organizations need to know that only patients have the provision under the ERISA law to appeal. Medical billers and healthcare providers have no rights at all – this is indeed the stipulation as per ERISA. Here are a few points that must be remembered with regard to ERISA, and which you can expect a medical billing company to know:

  • If the healthcare provider does not have a contract with the insurance company of the patient, the provider does not have any claim with the company. The claim is being sent not for the healthcare provider to be paid but for the benefit to be paid to the patient.
  • If the healthcare provider does not have a contract with the insurance provider of the patient, the insurance company does not have any legal obligation to send the patient’s benefit payment to the healthcare provider.
  • The only obligation of the insurance company is to its member or the patient’s employer. It has to pay the patient’s benefit according to the contract terms between the insurance provider and the member or employer.
  • As mentioned before, the right to appeal rests only with the member. If the insurance provider or medical biller does send an appeal, it is purely of the incorrect payment or denial of the patient’s benefit and not of the debt that is owed to the insurance provider.
  • It isn’t the insurance provider but the patient who owes the healthcare provider for the received services. The insurance company does not have any obligation to pay the healthcare provider who is non-contracted.
  • In the case of the healthcare provider being contracted with the insurance company of the patient, any kind of adverse benefit determination becomes a contractual matter between the provider and the particular insurance company. ERISA does not have any say here. Appeals made by the healthcare provider are according to the conditions of the contract the provider has with the insurance provider.
  • If the claim is denied though, it is a benefit being denied. The contracted healthcare provider needs to review the benefit manual of the patient to determine whether the denial is right or wrong. If the insurance company has paid the patient less, this is still a contractual matter and not an ERISA matter.

A medical billing company will have a clear idea regarding key points of ERISA (Employee Retirement Income Security Act). The experts at a medical billing and coding company are knowledgeable regarding ERISA and many such Federal and State regulations. Physicians and healthcare organizations seeking reliable medical billing services from a reputable medical billing firm definitely stand to benefit.

Meghann Drella

Meghann Drella possesses a profound understanding of ICD-10-CM and CPT requirements and procedures, actively participating in continuing education to stay abreast of any industry changes.

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