ERISA is Your Friend. Stop Denials, Recoupments & Illegal Activity by Carriers

Course overview

At the end of the presentation, the learner will be able to: - Identify whether a patient's health insurance claim is governed by ERISA, PPACA, or other regulations by analyzing the source and type of policy. - Locate and interpret the Summary Plan Description (SPD) to determine the true timely filing deadlines, appeal periods, and pre-authorization requirements. - Differentiate between the provider agreement terms and the patient's policy terms and apply the correct rules when they conflict. - Define an Adverse Benefit Determination (ABD) and recognize when a partial payment qualifies as a denial under ERISA standards. - Evaluate an Explanation of Benefits (EOB) for compliance with the five federally required components before an appeal clock begins. - Draft and send effective appeal and complaint letters to plan administrators, employers, and federal agencies citing specific ERISA and PPACA provisions. - Explain the federal limitations on insurance company recoupments and apply U.S. Supreme Court case precedents to protect provider revenue. - Implement strategies to involve employers in resolving claim denials and preventing insurer actions that increase employer liability. - Document and report carrier violations to the U.S. Department of Labor, citing appropriate sections of 29 CFR SS2560.503-1 and U.S. Code Title 29. - Use ERISA provisions to overturn denials for lack of pre-authorization when the patient's policy does not require it.