For hospitals, denied payments add up over time and represent a massive loss of revenue. They are costly, not only in terms of not receiving payment but also due to the time needed to properly file appeals. Health plans are accustomed to rejecting claims or reducing reimbursements according to their own established rates and policies.
Is it true that health plans have the last word in coverage decisions and reimbursement rates?
Often, they don’t. Most private-sector health plans are actually subject to the Employment Retirement Income Security Act of 1974. ERISA law can be leveraged when reimbursement is lower than expected, and other appeals have been unsuccessful. ERISA law sets minimum standards for most voluntarily established retirement and health plans in the private industry to protect individuals in these plans.
If you consider commercial insurance claims, ERISA might impact up to 80% of a hospital’s commercial claims and 60% of a hospital’s total revenues. Hospitals must adjust and include the ERISA appeals services to review and discover if ERISA can be applied to mounting debt.
Why are ERISA appeals so seldom utilized?
ERISA appeals take staff time and effort
Most hospitals are unable to dedicate the time or workforce to properly file an ERISA appeal to ensure a full and fair review. The dedicated team at Auraven takes on 95% of the workload to file a proper ERISA appeal. ERISA specialists discover which claims might be impacted by an ERISA and file the appeal. The hospital must provide the written-off or ‘bad’ debt data, establish a secure transmission of data and provide copies of commercial contracts. Thankfully, revenue recovery services can be added without impacting other revenue cycle management programs already in place.
ERISA appeals are complex
ERISA specialists employ a detailed process that is only utilized in 1% percent of hospital medical appeals. They provide the necessary intellectual data and process to identify and file the ERISA appeal in a non-aggressive strategy that leverages data the hospital does not have at its disposal.
In most cases, it is complicated to determine which written-off or bad debt claims an ERISA appeal might positively impact the hospital collections. At most hospitals, insurance disputes are understood to be worked through the health plans. Therefore, revenue cycle managers currently have no exposure to the concept of looking for collection or appeals opportunities in any other place. Most companies hire major TPA’s to manage the health insurance plans, so transparency is lacking in the ERISA process.
The process is further impacted by what is known as “balance billing,” almost all hospitals enter a contract with commercial insurance carriers not to balance bill the patient. Once the patient funds their portion of the hospital bill, the hospital might lose up to 60%- 50% of the in-network charges. ERISA applies to both In-Network and Out-of-network claims, and this allows ERISA to be leveraged and maximize the recovery process.
Hospitals need a special appeals department
Revenue recovery services become a hospital’s special appeals department. These specialists are the best at what they do, and they’re passionate about helping you.
At Auraven, we offer untapped solutions to help hospitals regain much-needed revenue, and we do it while ensuring every bit of information remains safe and secure. By using the federal ERISA appeal, it will ensure maximum benefit reimbursement or recovery for denied benefit claims. We exist to provide a specialized and unique service to hospitals with written-off revenue.
Hospitals can request a detailed ERISA audit to ensure a good fit. From there, an experienced ERISA appeals team will partner with you to build the best strategy for revenue recovery.
Auraven Health takes discarded non-government claims and files a federal ERISA appeal, protecting you against managed care.
Call us today at 833.927.7325