Like many providers, you probably find it frustrating to deal with plans governed by the Employee Retirement Income Security Act (ERISA) that don’t pay you promptly. They often miss the payment deadlines in state prompt-pay laws, and when you point that out, they say they’re not subject to those deadlines because they’re ERISA plans and subject only to federal law.
If your contract with the plan doesn’t set a time deadline, or if you don’t have a contract with the plan, you may think that there’s nothing you can do.
Fortunately, an ERISA plan isn’t exempt from any time deadlines, even if it is exempt from your state’s prompt-pay law. The Department of Labor’s (DOL) ERISA claims regulation that went into effect January 1, 2003 imposes deadlines by which plans must make decisions on claims. You can use that regulation to get decisions faster—which tends to also speed up claims payments.
To spur an ERISA plan to decide a claim that it’s holding, send it a letter pointing out the deadline in the regulation. “Sending such a letter is very effective. It also shows that you’re aware of the deadline and aren’t going to sit there and be taken advantage of,” says reimbursement specialist Tammy Tipton. It’s best if the member has first given you authorization to act as her representative or at least signed an assignment of benefits form. This way, the plan must send notices to you as well as to the member and has no excuse not to be in contact with you directly.
If you don’t, then the plan can argue that it need only notify the member, and members don’t always communicate with providers about the explanation of benefits forms they receive from their plans. But even if you only have an assignment of benefits form, that is usually enough to get notice of the decision on the claim, says South Carolina attorney Lawrence Laddaga. “The DOL said mere assignment is insufficient, but no court has,” he says.
This tip was excerpted from HCPro's monthly newsletter, Managed Care Contracting & Reimbursement Advisor. For more information, click here.
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