Physicians Practice

Richard was asked by Physicians Practice to write about the federal ERISA law and how doctors and care providers can use it to their advantage when it comes to their dealings with the health insurance industry. Among other things, the piece addressed the power of the health plan claims regulations that were put into effect by the U.S. Department of Labor in 2002 and how physicians and hospitals have not taken advantage of these regulations. In addition, Rick’s article explains how these regulations, that had previously only applied to private (company purchased) group health insurance plans, have now been expanded under the Affordable Care Act to apply to government plans as well.

As Richard explained in the article, entitled “Health Care Reform, ERISA Claims, & Government Health Plans”, the ERISA regulations are a veritable toolbox of goodies for doctors and hospitals. The frustrating and vague Explanation of Benefits forms that arrive in the daily mail are in violation of the law when they do not clearly explain why a claim is not being paid. In addition, there are special rules for claims where the health plan or health insurer alleges a lack of medical necessity or that a test or procedure is experimental or investigational. Claims falling under these two rubrics require an explanation of the scientific or clinical basis of the health plan’s decision, with specific reference to the patient’s medical condition. How often (if ever) have you seen a lawful EOB of this type?

Richard’s Article also addressed the 30 day rule in the regulations and the ramifications when health insurers violate the rule. This rule can come into play in both the clawback (recoupment) area as well as when challenging denied claims. Doctors should be aware that these tools can be used by them — as long as the legal posture is crafted by legal counsel steeped in ERISA’s history and knowledgeble about the applicable law.

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