The first step to filing ERISA appeals is to ensure you have all the ERISA documents you need from your patients — but that can be easier said than done. It can be challenging to get items like the summary plan description and coverage details.
Check these methods that can help you gather the ERISA documents necessary for submitting winning appeals.
During Pre-Verification of Benefits
When a patient first calls your practice to make an appointment, you’re likely to perform a pre-verification of benefits. This requires you to get their insurance information and evaluate whether they have government or private insurance. If it’s the latter and it’s through an employer, there’s a good chance it falls under ERISA.
While you’re still talking to the patient, it’s an optimal time to ask for plan documents like the summary plan description. You can ask them to bring those files to the first appointment with them, which will allow you to get a clear picture of their deductible, copay, coinsurance, coverage guidelines and more.
When the Patient Comes to Your Practice
If you didn’t have a chance to ask the patient for their ERISA documents over the phone, you should ask for them when they present for their appointment. If they say they don’t know where to get that information, let them know they can acquire it from their insurer or potentially through their health insurance portal. In some cases, their company’s HR department might have a place where that information is available instead.
Via a Permission From During Onboarding
If the above two steps fail, you should consider obtaining written permission from the patient, which would allow you to receive all relevant information. For instance, you might consider asking them to sign an “authorized representative” form as part of the documents they complete at the initial visit.
If your practice doesn’t request these documents up front, it may save you time when onboarding the patient, but it could cost you both time and money later because you were unable to lay the proper foundation for ERISA appeals. If you ever do get into a dispute with a payer and you want to file an ERISA appeal, the documents you gathered early on in the relationship will help protect you for the future.
Mastering ERISA can help your practice bring in more cash by giving you the tools you need to appeal denials. Find out how to use ERISA to your advantage with tips from Radha Pathak, Esq., and Dana Berkowitz, Esq. during their latest online training, Boost ERISA Claim Payments with Simple Intake Process Changes. Register today!
Check out our Appeals Playlist on YouTube for the latest expert advice, and subscribe to our YouTube channel for step-by-step guidance!
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