ERISA - EMPLOYEE RETIREMENT INCOME SECURITY ACT

WAIT - IT'S NOT WHAT YOU THINK

ALL INSURANCE CLAIMS PROVIDED BY EMPLOYERS?

WAIT - IT'S NOT WHAT YOU THINK

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.

THIS AFFECTS ME?

ALL INSURANCE CLAIMS PROVIDED BY EMPLOYERS?

WAIT - IT'S NOT WHAT YOU THINK

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.

ALL INSURANCE CLAIMS PROVIDED BY EMPLOYERS?

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!

HOW DOES THIS AFFECT MY CLAIMS?

DOESN'T STATE INSURANCE LAWS HELP?

ALL INSURANCE CLAIMS PROVIDED BY EMPLOYERS?

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.

DOESN'T STATE INSURANCE LAWS HELP?

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.

HOW DOES ERISA AFFECT ME?

DOESN'T STATE INSURANCE LAWS HELP?

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.

95% IN MEDICAL FIELD KNOW NOTHING OF ERISA

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.

YOU SAID THEY CAN'T RECOUP?

95% IN MEDICAL FIELD KNOW NOTHING OF ERISA

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.

BUT THEY RECOUPED FROM ME ANYWAY

95% IN MEDICAL FIELD KNOW NOTHING OF ERISA

BUT THEY RECOUPED FROM ME ANYWAY

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.....

WHAT ELSE DOES ERISA AFFECT?

BUT THEY RECOUPED FROM ME ANYWAY

ERISA can make the carrier pay when they don't want to.
ERISA can stop the carrier from down-coding the claim anytime they wish.
ERISA can stop the carrier from making up ridiculous bundling policies.
ERISA can stop a carrier from claiming a service is investigational or experimental,
and more

HOW CAN I LEARN MORE?

WHAT ELSE DOES ERISA AFFECT?

HOW DO I KNOW THIS WORKS?

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 2 hour webinar that includes the book (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.

HOW DO I KNOW THIS WORKS?

WHAT ELSE DOES ERISA AFFECT?

HOW DO I KNOW THIS WORKS?

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 & ASSOCIATES, ERISA DIVISION

LET US STOP THOSE REFUND DEMANDS

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.

Frequently Asked Questions

Please reach us at donself@donself.com if you cannot find an answer to your question.

1. Does ERISA only apply to Fully Funded Insurance Policies

No, ERISA applies anytime the non government or non church employer provides insurance (medical, dental, life, etc) policies to an employee.

2. How do I get a copy of the patient's insurance policy?

Ask! Tell the patient you need a copy and explain that the reason you want it is to make sure the patient's insurance is paying the claim properly so that you do not have to bill the patient.

3. Where can the patient get a copy of their policy?

Their employer has to provide it to the patient within 30 days of the request or the employer can be fined $110 a day, dating back to the date of the original request. Have the patient request it from their employer. Some practices in the country will not see a new patient with insurance unless the patient provides the copy or link to the provider of the policy. Those practices usually have close to a TRUE 100% collection ratio on their charges. I wish more followed that policy.

4. A carrier approved my pre-authorization and then denied the claim saying pre-auth was not approved. Can ERISA help?

DEFINITELY. Many physicians, providers, clinics and managers believe the contract or agreement they signed with an insurance carrier somehow obligates them to get pre-auth on all or some of the procedures they perform. The ONLY time that pre-authorization is a requirement for a claim is when the patient’s insurance policy stipulates that the pre-authorization is required. The provider-insurance company agreement is 100% trumped by the patient’s policy.

The easy answer is to look at the patient’s policy to make sure it is not required and then send a letter to the CEO of the carrier (and the employer) asking if they really want you filing a complaint with the US Department of Labor that might result in the carrier AND the employer getting fined. The last thing that the carrier wants is the CEO of the employer getting that letter. If the employer believes they are at risk of getting into trouble because of something the insurance company did - the carrier is forced to follow the rules!

5. When my doctor files a claim and accepts assignment, doesn’t that somehow make it the doctor’s claim? I was told by a carrier that when the patient appeals - they have more rights than when the doctor appeals.

No – it is NEVER the doctor’s claim or the hospital’s claim (unless the doctor is the patient). The policy is owned by the policyholder (patient) and the claim belongs to the policyholder or patient ONLY, which is a good thing because the patient’s claim is protected wheras if it were the provider’s claim – it wouldn’t be. The patient's policy and rights are protected regardless of who files the claim or appeals the claim.

6. My hospital received a claim denial for timely filing. Our agreement with the insurance company says we have a 90 day timely filing. Doesn’t that somehow trump or over-rule the patient’s policy that says a 1 year timely filing?

Absolutely NOT. The patient’s policy ALWAYS trumps any agreement the medical provider may have signed with a carrier in the same way the Federal ERISA law always trumps the state laws or state insurance regulations.

7. My state has a law or regulation saying insurance carriers cannot recoup money from a medical provider on a claim that is over 2 years old. Does ERISA follow that?

No. the federal ERISA law says that they can NEVER recoup from a medical provider and if they want the money they “claim” to be owed, they would have to seek it from the patient. The uS Supreme Court has upheld this numerous times.

8. Did I read that it is illegal for someone at the insurance company to lie to a medical provider or patient to keep from paying a claim?

ABSOLUTELY. Title 29, Subsection 1140 and 1141 says it is a federal civil and criminal violation. Title 29, subsect. 1140 (civil) and 1141 (criminal) carry very steep monetary and incarceration penalties for misrepresenting benefits or preventing the exercise of ERISA rights. If you have a signed authorization making you a duly designated and authorized representative of the patient you take the patient's place in the appeals process, therefore they cannot misrepresent benefits to you either

9. I work for a hospital and we have insurance carriers almost constantly sending us REFUND or RECOUP letters. I told my CFO what you said about the ERISA law prohibiting the carriers from recouping and she said that our attorneys know all about ERISA. If that is the case - why do we let carriers recoup Millions of Dollars from us?

There are 4 Titles to ERISA and almost all of ERISA deals with pension plans, retirement plans, what plans are pre-tax deductible, how to safeguard the guarantees of pensions, etc. The area of ERISA dealing with Adverse Benefit Determinations (claim denials) and recoupment and disclosure is a small part of ERISA - although to us in the billing or coding or revenue side - it's HUGE. The hospital's attorney knows about ALL of the pension side but probably knows NOTHING about ERISA from the claims standpoint. Unfortunately, many attorneys and many CEOs and CFOs refuse to admit what they do not know about. It is really sad how many hospitals let carriers do what they do out of plain ole ignorance.

10. We have a 30 day appeal period with a major insurance carrier in our agreement. When is that 30 day appeal period valid?

It is ONLY valid when a patient receiving service from you is covered on a policy provided by a government or a church employer. In other words, the 30 days is valid if a police officer's spouse comes in, or the pastor of the local Baptist church or the spouse of the groundskeeper at the Catholic church or the Postal worker. Anyone getting their insurance from a non government or non church employer is a MINIMUM 180 days by Federal Law. The 30 day appeal period in your agreement does NOT apply to ERISA CLAIMS

11. Did I read that more than 80% of commercial claims are ERISA protected?

Yes - unless you live near Washington DC, it is probably closer to 84% of claims. Anyone getting their insurance from Starbucks, Kroger, Target, Fedex, Home Depot, Amazon, Walmart, United Healthcare, Kraft, Berkshire Hathaway, Dairy Queen, Duracell, GEICO, UPS, CVS Health, Aetna, BCBS, Apple, Exxon Mobil, Microsoft, McKesson, Cigna, General Motors, Ford, Toyota, Walgreens, AT&T or any of the other 7.2 million non government and non church employers in the USA are ERISA claims

12. How can I use ERISA to win against these carriers? Do I have to take them to court?

In teaching and helping practices with ERISA for about 25 years, I've never filed a lawsuit or had to take any insurance company to court. The best way to win is to learn how to use ERISA. That is why we wrote a book that we are updating yearly (sometimes more than once a year) and why we teach dozens of ERISA webinars a year on it. You can get the pdf book with the letters that you can copy/paste onto your letter (they work) and the webinar to teach you at this link. Just one claim getting paid more than pays for this book/webinar combination. Read more on it and order it at https://donself.com/shop/ols/products/erisa-special-offer-package-book-webinar

13. We received a letter from a large insurance company saying we had 30 days to refund them on a payment where the patient was not eligible or they would recoup it from another claim. What can we do?

You can almost always stop them if you act quickly enough and follow our suggestions. You need to send a letter to the Plan Administrator and copy the employer letting them know that the ERISA law and the federal courts and the U.S. Supreme Court has said it is ILLEGAL for them to recoup from the medical provider. Remind them that if they do as they are threatening, that you will consider filing a complaint with the US Department of Labor and quote the law. They do not want the employer getting fined. That usually wins. You can get the letter in our ERISA book at https://donself.com/shop/ols/products/erisa-special-offer-package-book-webinar

14. The Insurance Carrier already recouped. They did not give us a warning! What now?

Now you need to send the Plan Administrator, the Insurance Company CEO and the Employer a letter (also found in our book) letting them know they have violated the law and they have 10 days to get that recouped money returned to you or you will consider filing a complaint with the US Department of Labor. We have hundreds of folks (some with quotes at the bottom of this page) tell us that letter works 100% of the time.

15. The carrier denied our claim saying it was due to investigational/experimental reasons. What now?

The denial of anything on the claim or failure to pay 100% of what they should on any line item of the claim makes it an ABD (Adverse Benefit Determination). Now - it's time to look at the patient's policy to see if that service they are denying is listed as being on the investigational or experimental list in the policy. If it's not there….. they have to pay it - so follow the steps and send the letter in the book for that purpose and wait for the check.

16. The carrier bundled two codes together and denied one of them. We checked the NCCI edits and they should have paid for both as we used the right modifier.

There is a letter in the book that you can send to the carrier, and they must respond within 30 days as that is the time limit they have. They are required to follow the "standards of the industry" which is set by CMS (since they process more claims than all other carriers combined). Use the letter and you'll be surprised at how easy it is.

TESTIMONIALS

"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 dmartinez@accuratemedbilling.com 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 ziaclarkson@gmail.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 lois.a.simmons@osfhealthcare.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 billing@hhobgyn.com

Billing Manager

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 “ ollielooya@yahoo.com

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, jessica@amdglobal.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 delorenzo_fmly@sbcglobal.net
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 cindy@tricarefamily.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 heather@tapiaclinic.com

"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 virginia@familyallergyatx.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

lmeadows@advancedsurgery.com

"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 b.cobuzzi@att.net

www.CRNHealthcare.com

"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 <officemanager09@gmail.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 krystalspencerwork@yahoo.com

"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 stacy@midwivesadvantage.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, hodgec@sjchs.org