Tips for Collecting Your Health Care Claim against Self-Insured Health Plan

TASA ID: 3307

Obtaining reimbursement on a health care claim is not easy today because of all the different laws and regulations and insurance plans.  I recently worked on several cases to recover claims involving a large self-insured health plan. All self-insured plans are governed by the federal ERISA law and have “trustees” to administer the Plan. Many health care providers, including surgeons, surgery centers, chiropractors, and physical therapists have had their legitimate claims denied over recent years because of alleged fraudulent claims, but legitimate claims are payable.

Here are tips for you to maximize an insureds or a healthcare provider’s efforts to obtain payment on self-insured health care claims:

  1. Request a Full and Fair Review of Your Claims.  ERISA requires that you first exhaust your administrative remedies.  To do this you must request, in writing, a “full and fair review” of your claims by the trustees.  Your claim is deemed denied if you do not hear back within 30 days of your appeal.  The Plan trustees have to respond to you within 30 days of your request, unless your documents are incomplete or they request more time in writing.
  2. Obtain a Copy of the Plan’s Grievance and Appeal Provisions.  Every plan participant is entitled to obtain a copy of this procedure.  It usually is contained in the Plan Summary Plan Description which is given (or should be given) to each insured, or it could be a separate document.  Follow the procedures, in writing, contained in this document.
  3. Request A Review By the Coast Arbitrator. If your claim still is not resolved at the trustee level, you can request an arbitration or a court hearing if arbitration is not available.  Do this in writing. The expenses of the arbitrator are usually paid by the Plan.  There is usually just one arbitrator for all health care claims, but each plan is different. You will be given an opportunity to provide an opening statement and to respond to briefs by the Plan lawyers.  Definitely respond with any documents that have not previously been submitted and argue your case. You can waive your right to an in-person meeting.
  4. Hire An Experienced Lawyer Who Knows ERISA.  You can hire a representative, called an “authorized representative” to do all of this for you. That person can be an attorney. The Plan trustees will have lawyers involved in the arbitration. Separate lawyers will usually represent the union trustees and the employer trustees. 
  5. Sue Under ERISA.  If this still does not resolve your claim, you have the right to sue under ERISA.  If you prevail, you can recover your attorneys’ fees and the health care claim will be paid. The ERISA claims regulations are found starting at 29 Code of Federal Regulations 2560.503-1.

In sum, do not give up. Find out your rights and enforce them.  If you have a good claim, it is likely it will be paid if you fight. 

This article discusses issues of general interest and does not give any specific legal or business advice pertaining to any specific circumstances.  Before acting upon any of its information, you should obtain appropriate advice from a lawyer or other qualified professional.

This article may not be duplicated, altered, distributed, saved, incorporated into another document or website, or otherwise modified without the permission of TASA.

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