Health Insurance | ERISA
In the complex and fast changing world of health plans and health insurance, one things remains the same: the vast majority of health plans and health insurance policies are sponsored by employers or groups, which makes them governed by ERISA, the Employee Retirement Security Income Act of 1974. This federal law — unknown to many — is a powerful set of laws and regulations that can be applied to obtain fair treatment and protection to medical providers in the United States. The fair protection comes in the form of opposing and defeating post payment audits, claw backs, and recoupment of funds previously paid by health insurers. This frequently occurs through retrospective audits. Our firm also uses ERISA to collect sums due to medical providers on denied claims. Medical providers need to be educated about this law and then must have proper counsel in order to take full advantage of the tools available here.
When a claim is received and handled by a health plan (self-insured) or a health insurer (group insurance policy), the entire process is governed by federal regulations. And the relationships between patients, medical providers, health plans, and health insurers are all controlled by the ERISA law itself. Here at QLG, there is no dispute about this. The United States Supreme Court — has told us, over and over again, for 30 years, how ERISA works and where and how it applies. But the trick is knowing how to use it to help medical providers in their contentious relationships with health plans and health insurers.
The next challenge is for doctors and other medical providers to have confidence that, yes, you indeed have leverage. And yes, the law can work for you — not against you. All you need is the right legal team on your side and the confidence to know that the team is uniquely qualified to resist an audit, fight off a recoupment / refund demand, stop claim offsetting, or help you get paid on claims.
Quadrino Law Group uses ERISA as one of the main tools in working to help medical providers across the country. Combining 20 years of ERISA know-how with 20 years of insurance industry and claims experience is how QLG’s Health Insurance | ERISA practice group achieves its successes for clients.
So if claims are being delayed or denied, we can help. If you are at wits end and want or need to take it further, we are here for you — and you’ll learn how we can pursue a successful resolution.
When an audit comes: not to worry. You’ll be shocked to learn about how ERISA can “take over” even though you signed a provider agreement with some scary wording in it. Fear of retaliation? No need: ERISA can cover that too.