Medical Reimbursement Consultants since 1988, serving tens of thousands of physicians
Medical Reimbursement Consultants since 1988, serving tens of thousands of physicians
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When most people see the "retirement" and "security" in the name of the ERISA law - they think "oh - it applies to securities and investments and that stuff - and it does - but that is NOT what affects EVERY medical office, every clinic, every hospital and every medical biller. The Medical side of ERISA is amazing.
When an employer provides health insurance to an employee - it falls within the "compensation" arena, the same way the salary, vacation, holidays, overtime, etc. does.
This means the patient and insurance policy is NOW protected by the federal government and the 1974 ERISA law - which is a GREAT thing for medical providers, hospitals and clinics.
About 83% of ALL non Medicare and non Medicaid medical claims fall within the ERISA purview. If the insurance is provided by a non government or non church employer, the policy is ERISA.
That's a good thing for you and the patient as it gives the patient's policy more protection. This means people working for Walmart, Exxon, Mobil, Carrier, Fedex, and every other non church and non government employer have ERISA policies!
Contrary to what you thought - YOU don't have any claims. It's NOT your policy and it's NOT your claim. It is the PATIENT'S claim - and that is great news for you as that claim is protected by the Department of Labor, whereas if it was YOUR claim - it would have zero protection.
If it's an ERISA claim, then the state insurance laws do NOT help and they do NOT apply. The federal protections take precedence over state laws, state insurance regs and even the contract you may have been dumb enough to sign with the carrier. Your contract cannot interfere with the federal protections that claim has.
You "think" you have a timely filing limit of 90 days or 120 days with a carrier.
That claim, that belongs to the patient, that you filed does NOT have that timely limit. Your contract with the carrier means NOTHING since the patient's policy is ALL that matters and most patient policies have 180 days or 1 year and some even have 2 years.
Insurance carriers are counting on the fact that less than 5% of people in medical offices or hospitals know anything about ERISA.
They know they can't legally recoup -but they do it anyway. They know the timely filing limit in your contract means nothing on more than 80% of the claims you file to them - but they know that most medical offices and hospitals are ignorant of that fact.
The claim is NOT your claim. It's the patient's claim - and therefore it's the patient's money. The Supreme Court has ruled several times that if the carrier wants money back - they have to get it from the patient - and NOT the medical provider.
The fact they mailed the check to you means NOTHING - regardless of the lies told to you by the insurance carrier in the letter they send you full of false information.
Of course they did. They banked (literally) on the fact that you were ignorant about ERISA - yet you could have stopped them from getting an insurance carrier refund from you very easily.
It's probably not too late to get them to refund to you the money they recouped. They don't want to be sued like BCBS did. That case ended up with the carrier paying more than $350 Million - and they don't want to pay that again.....
You can watch a free 10 minute video on ERISA on Youtube.
You can order a printed book or the same book in pdf in our web shop.
You can download a very popular one hour webinar movie (with the pdf slides) on ERISA that you will have on your computer and let everyone in your office watch it anytime you wish to.
GREAT QUESTION! Look below at the comments from people you may know - who have attended our ERISA webinars or bought our books and used that data to make carriers play by the rules
If you want to verify any of these - just ask and we'll give you their email address if it's not shown below.
Don Self and Associates announces a new division working directly with ERISA-related claims. Joseph Self, current Director of Operations is named Head of Department.
You're tired of carriers recouping from other claims. You're tired of carriers sending you recoupment demands telling you to write them a check. DSA-ERISA has a solution to stop the leak of cash flow.
DSA-ERISA currently has a limited number of slots available as partner clinics. These clinics will have the ability to send qualifying recoupment demands or previously performed recoupments to DSA-ERISA to allow us to coach you through the procedure to have these demands dropped, or previously recouped monies returned to you.
Fee for service to DSA-ERISA is on a success-based model at 25% of the claim amount, recouped or recovered recoup. This means you only pay when we save you the money and only 25% of what we save you.
If you're interested, keep reading.
As you know from reading my book, The Unfiltered Guide to ERISA for Medical Providers, carriers are required to follow certain claims procedures and follow certain requirements in regards to denials, adverse benefit determinations, timelines, and more. Due to ERISA there have been several Supreme Court decisions that have set precedent for how carriers must request money or "recoup" money they deem owed back to them.
In the most basic form, a claim ALWAYS belongs to the patient, you're just the "middle-man" that is filing the claim for them, regardless of what your assignment of benefits says or your contract with an insurance carrier. This is how it's mandated in federal law CFR 2560-503-1 in ERISA. It goes on to say that no contract or agreement can attempt to overwrite or contradict the Act. What this means is if a carrier pays for a claim, and retroactively issues an adverse benefit determination, they must follow certain notification guidelines, as well as, they must request the money back from the claimant, not the provider that performed services for the claimant.
IMAGINE THIS: The carrier sent the check to the patient and the patient cashed it at the bank and a few days later, brought cash to your office and paid their bill on the services you provided them. Six months later, you get a letter from the insurance company saying “We want that money that the patient brought into your office six months ago”. You would laugh at them!
The above scenario is what happens thousands of times a day, and we're done sitting around watching people get taken advantage of. Let's get to work.
"I have been using Don Self's methods from his webinars and books. We have stopped every single overpayment request! Yes, every single one! My staff estimates in 2017 about 270 times and in 2018 about 60+. A dramatic drop from one year to another. The payers know we are going to call them on their BS. We literally get clients contacting us just to write overpayment letters. Because they have heard from other clients. I just got a call asking "are you the dude (we are in California) that stops the insurance company's overpayment retractions?" David Martinez, Owner, CEO, CMRS, CMBS, CCPB, CCBS, CPC-P, CPC-I, CCA, CBCS, CCPC, CMB, CHP Accurate Medical Billing & Audit Rancho Cucamonga, CA firstname.lastname@example.org www.AccurateMedBilling.com
"We had an out of network surgery with innovative services on a small child done by a pediatric surgeon. Many unlisted codes, all told 132,000$ surgery. Originally they paid $648.00, Medicare rate. After ERISA appeal, they paid 64,000$, the 50% of billed charges as the plan spec outlined. It works. I had to share. "
Zia Rivera-Clarkson MBA MDiv CPC BCS EHR MAA CBCS email@example.com
Adjunct Professor, American Business and Technology University
Director of Coding, Auditing and Compliance, The Patriot Group
Don is an expert on ERISA. His advice works. If you are having problems with an insurance, I love his advice to contact the insurance company CEO. I used this tactic last week for a patient and the patient received a call from the CEO the next day and the issue was resolved within 3 days. Rhonda Crouch CPC, RGCrouch@crmchealth.org
"I have used Don’s books, Coding Advisor, slide rule and I am love them all. They are done so expertly yet are so easy to use. Don is a great resource to anyone in the coding field. "
Lois A Simmons, RHIT, CCS-P firstname.lastname@example.org
Coder/Abstractor, OSF Medical Group Surgery Peoria, IL
"Don, your advice was right on the money! I received a request for a refund due to policy termination and responded on 06/30/15 with your letter from your book addressed to the CEO. I was delighted to receive a call on 07/07/15 indicating the request had been made in error and to disregard it. How refreshing to have something work the first time and immediately. Please feel free to share this to encourage them to get on the ERISA band wagon. " Mary Bergstrom St. Cloud Ear, Nose & Throat Clinic St Cloud MN Mbergstrom@stcloudent.com
"Can't stress enough to you all how effective it is when you send your complaints directly to the CEO/Attorney's of the Insurance Companies. I had sent an appeal to Anthem 3 times without a response and then tried to contact our Provider Rep and couldn't get a response from her either. I typed up a letter to the CEO explaining how this lack of response was "In my opinion' a violation of the ERISA and said if I received no response within 5 days we would look into a potential law suit with punitive damages. Low and behold I got a call from our Rep THE NEXT DAY!"
Lori Braidic email@example.com
HER HEALTH OB/GYN, Columbus, Ohio
"How appropriate to end the day with notification from a major insurance company that an appeal previously denied for timely (due to the 90 day payer contract) was successful! Prior attempts the "conventional" ways had failed and without the ERISA knowledge the claim would have been written off. "---Suzanne Byrum CPC, Everett, WA “ firstname.lastname@example.org
No more refunds request! Don Self is the most experienced and knowledgeable consultant in the insurance healthcare field! Thank you Don for all that you do! God bless you!
Jessica Monge, email@example.com
"Just an update on the UHC claim that was recouped after 19 days. I sent Don's letter to the CEO of UHC. I added a few other points of interest like my call log to them trying to clarify the situation and their agreement to put the recoup on hold. I was able to track down the CEO email address and sent it yesterday. I received a call today from his office stating they had researched what I stated and they are attempting to correct the issue and will repay the recoupment once the data has been updated. He assured me that I would receive the money back and he would be following up with me until it is resolved. I was able to get his direct phone contact information as well. If you haven't started to stand up to them you need to. If enough of us start fighting back maybe they'll get the hint that we aren't going to roll over."
Regina DeLorenzo firstname.lastname@example.org
Practice Administrator, LifeMine Health, Willowbrook, IL
"I have had so MANY problems with my own insurance policy which is ERISA.. and double whammy.. UNION plan.. Friday, I picked up my mail and they paid all claims I had in appeal using ERISA.. THANK YOU DON!!!!! In all my years of working in this business I never realized how much ERISA really mattered until you taught me.. Linda Walker” Practice Managers Resource & Networking Community
I normally don't buy "work" books unless the company pays for them, but after using Don's website and his medical list serve for years now, I felt they would be well worth my money and, boy, they have been. The ERISA books have helped me get claims paid and recoupments reversed. The sample letters have made my job much easier, too! You need all the help you can get in medical billing and I highly recommend all 3 of his books, his newsletter, his free list serve and his coding software.
Cindy Block, Billing Manager
Tri-Care Family Medicine email@example.com
Anytime an insurance company has requested a recoupment or takeback in the past, we would just hand it over...until now. I did my first ERISA appeal to BCBS and within 8 weeks, received a letter that the decision had been overturned!!! We "won"! BAM. Its been a huge plus for our practice. Heather Ray Billing Manager TIMC - Paris, Texas firstname.lastname@example.org
"This is not a subject they teach in school and every medical office needs to have knowledge of this subject." Virginia Hart Craig Austin Family Allergy, Austin, TX email@example.com
"He provided me with a new path for appeals. Even after 34 years in billing and coding it is always exciting to get those "AH HA" moments that will help increase your revenue. Lynn Meadows Advanced Surgical, Mesa AZ
"If you do not have ERISA tools in your denials toolbox, you are walking around with an empty toolbox and are unable to optimize the compliant income your providers worked for and should be paid for." Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS firstname.lastname@example.org
"Highly recommend! I learned there is help to fight back, great examples to help you take the correct steps, and the right verbiage to make your case!" Melanie Rowls, Practice Consultant <email@example.com>
"If you bill insurance, you need to know about ERISA. Don't just give your money away!" Linda Vargas University Physician Associates, Kansas City Linda.Vargas@tmcmed.org
"I started a new job with a large DME company and they had tons of recoup letters and getting more daily. I sent Don Self’s letters on the ERISA claims and 6 weeks in guess what?! No recoups and zero letters received yesterday in Monday’s mail. I don’t think this is coincidence and hopefully they will leave us alone! Thank you Don!!!!" Krystal Spencer, Nashville, TN firstname.lastname@example.org
"We have the same testimony in that we win all the time using Don Self's methods. I might have changed the language a little and told them to kiss it!! I’ve had several calls from assistants to CEOs attempting to calm me down. I wasn’t very understanding. They got the message loud and clear. " Stacy Carruth, National Birthing Centers, San Antonio, TX email@example.com
"I have been following you since 2009. I have purchased a couple of your books as well as Jin Zhou books. I have been billing and consulting for 30 years . I can honestly say that learning ERISA from you has defiantly been a positive adjustment and has contributed to increased revenue for my docs. I refer every single one of my clients’ staff to your site as a valuable resource. Thank you for all that you do. Respectfully, LisaMarie Partridge, CMC, CMIS" LISA@HNPCS.NET
"I have been following Don Self for over twenty years. I have used many of his free forms over the years. His webinars are always very informative. He is always current on the constant changes in the coding world." Carol Hodge, firstname.lastname@example.org