It happens from time to time: Your provider agreement dictates one time period as the timely filing deadline, and the patient’s policy notes a different time period. If this discrepancy is confusing, that may be because insurers like it that way. However, if you have ERISA on your side, you can sort through this issue and appeal successfully to get the money you deserve.
Read on to discover how having ERISA on your side can help you navigate discrepancies in timely filing deadlines so you can bring in more pay.
Why Discrepancies Happen
Insurers sometimes create contracts with medical professionals that are deliberately stifling. For instance, they may say you have just 90 days to submit claims after the date of service, and just 60 days to appeal thereafter. Your provider may sign this contract because your office wants to get paid by that insurer for services, and perhaps your office staff then thinks these deadlines are written in stone.
But the reality is that the insurer maintains these tight deadlines because they’re favorable to the payer, not to your practice. However, because of the ERISA laws, you may not be bound to these deadlines.
Why the Patient Policy May Supersede Your Contract
Depending on your patients’ payer, their policy may be subject to ERISA laws, which is a shorter way of describing the Employee Retirement Security Act. These laws govern most employer-issued, private payer (non-Medicare and non-Medicaid) policies that your patients have.
Because ERISA is a federal law, it supersedes (or pre-empts) state laws and many breach of contract claims. In other words, if a court were to weigh in on whether an insurer should follow ERISA laws or your physician’s contract with a payer, ERISA will usually win.
How ERISA May Help You Appeal Timely Filing Denials
The timely filing deadlines imposed in your physician contracts are usually shorter than those dictated by the policy that the patient has with their insurer. For instance, the physician contract may say the timely filing deadline is 90 days after the date of service, while the patient’s contract says the timely filing deadline is one year after the date of service.
If the patient’s policy is covered under the ERISA laws, the timely filing deadline in the patient’s contract with the insurer is the date that the insurer would be expected to honor.
This means that if you get a timely filing denial due to the date in the physician’s contract, you can appeal based on the patient’s contract with the insurer under the ERISA laws, asking for the payer to honor the one-year period as dictated in the patient’s contract with their insurer.
If you’re appealing on these grounds, you should submit a copy of the patient’s contract with their insurer (which the patient can get from their employer-sponsored plan administrator) and a copy of the ERISA law to back up your appeal.
If you speak to someone at the insurance company who hasn’t heard of ERISA, ask to be transferred to the plan administrator for your patient’s payer. If needed, get a healthcare or labor attorney involved who can help you fight the denial, citing ERISA for support.
Want to know more facts about how ERISA can help you collect more pay? Join expert Don Self, CPC, CMCS, CASA, during his online training event, Overturn Rejected Claims: ERISA Appeal Letters to Get You Paid. Register today!
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