Hospital Claims Recovery

Erisa Helps Hospitals

Collecting claims and payments for hospital services can be extremely challenging. The number of employees and man-hours required to simply collect payments can be very expensive. Also complicating the process is the federal Erisa law. As experts in this area, Erisa Recovery brings a wealth of knowledge and experience assisting hospitals in their negotiations with payors, insurance companies, and contract intermediaries.

The Federal Erisa (Employee Retirement Income Security Act) Law could be the most misunderstood law in the United States. Erisa Law is not taught as a core subject in law school, and less than 2% of attorneys have ever even studied it as an elective. But understanding the Erisa Law is crucial to being able to intelligently appeal and collect denied insurance claims as a patient advocate.

According to the Erisa Law, healthcare denial is defined as “anything less than 100% payment of the claim,” meaning full charges – not simply the PPO amount. By properly applying this law, Erisa Recovery can help hospitals potentially deliver substantial portions of the contractuals for any claim where the commercial insurance coverage was issued by an employer’s self insured plan. (Government, church, and a few other minor categories are exempt).

There are no upfront fees for our services in the administrative appeal process. All fees paid to us are a percentage of new claims payments delivered directly to the hospital. There is absolutely no risk to the client hospital, and our payment is contingent on our client getting paid first. Our proven approach has been utilized successfully by hospitals and other providers all across the United States for over ten years.

Did you know:

• While the Department of Insurance governs fully insured employee healthcare plans, the Erisa Law governs self insured employee healthcare plans, which make up two thirds of all current health insurance coverage in the US. The “insurance company” is actually not the company that issues the policy; they simply provide administrative services as a claims processor, and they provide the PPO network.

• All contracts written by the network, PPO, HMO, etc. are superseded by the Erisa Law, as well as all state laws and all insurance company rules. Therefore, two thirds of all healthcare plans in the US are strictly bound by the federal Erisa Law.

• The Erisa Law asserts that “anything less than 100% payment of the claim” is considered a healthcare claim denial, and is therefore eligible for appeal.

• Any third party who administrates claims and provides a PPO network is defined merely as an “agent” of the employer. This means the employer is still legally considered to be the fiduciary.

• If the employer promises 80/20 financial responsibility for employee health bills, but the “agent” only pays 40%, the remaining 40% is defined as a denial and is therefore considered appealable under Erisa rules.

• All disputes, claims, and appeals over benefits paid under employer sponsored healthcare plans are bound by very specific Erisa procedures.

• Our claims recovery process acts as a virtual appeals department, providing an outside service that makes full use of the administrative appeal process defined by Erisa.

• Thanks to our highly trained and experienced recovery team, we’ve helped recover millions of dollars for providers across the US. Our rate of recovery ranges from 10% to 40% of previously written off denials on cases dating back to January, 2003.

• Our claims recovery services requires minimal involvement from hospital staff. Initiating our service takes only about three hours of set up time, and one hour per month for maintenance.

• Our service has been thoroughly vetted by multiple clients through law firms and state hospital associations, affirming all statements to be within Federal Erisa Law and procedures.