We are increasingly seeing commercial health insurers taking aggressive — sometimes illegal — positions with respect to claims being submitted by health care providers, and delaying or denying legitimate claims for services. Many commercial insurers fail to follow not only their own procedures but also fail to follow ERISA rules for claims processing with respect to the employer-sponsored plans they administer, as well as state prompt pay rules. Timely and aggressive challenges to these abusive claims handling practices by legal counsel can make a difference.
Understanding ERISA Rules for Claims Processing
ERISA, the Employee Retirement Income Security Act, outlines important regulations that govern the processing of claims for employee benefit plans. These rules are critical in ensuring fairness, transparency, and efficiency in handling claims related to health care, disability, retirement, and other employee benefits.
- Adequate Notice and Explanation: ERISA requires that claimants receive a clear, written explanation detailing the specific reasons for any denial of benefits. This ensures that claimants fully comprehend the decision made by the plan.
- Timely Decisions: ERISA stipulates that benefit plans must make a decision on a claim within a reasonable timeframe. Delays in processing can be contested under ERISA rules.
- Full and Fair Review: If a claim is denied, ERISA mandates the right to appeal and have the denial reviewed by the plan. This appeals process ensures a fair and unbiased reconsideration of the claim.
- Access to Records: Claimants have the right to request and obtain documents and information relevant to their claim. This access facilitates an informed and thorough appeals process.
- Fiduciary Responsibility: Plan fiduciaries must act in the best interest of participants and beneficiaries. They are legally bound to manage the plan prudently and in accordance with ERISA guidelines.
Understanding and navigating these ERISA rules is crucial for both healthcare providers and plan participants. At Nicholson & Eastin, LLP, we specialize in guiding healthcare providers through the complexities of ERISA regulations. Our team of experts can provide the necessary legal assistance to ensure compliance with ERISA rules and protect the rights of all parties involved.
Experienced Florida Healthcare Attorneys
The attorneys at Nicholson & Eastin, LLP regularly represent healthcare providers in claims and payment disputes with insurance companies, Medicare, Medicaid, and other payors. Whether it is a claims audit, prepayment review, or overpayment demand, our attorneys — including a certified professional coder — can offer legal guidance and intervention to expedite or improve the outcome.
Seek The Advice of Counsel
Occasionally our physicians and other healthcare providers clients have a payment dispute with an insurance company that reaches the point where litigation becomes necessary. If you have a payment matter or dispute that has reached the point of litigation or otherwise requires attorney intervention, please contact us to schedule a consultation.
Contact Nicholson & Eastin
If you’re facing challenges with payment disputes, and claims processing, or need legal intervention in the healthcare industry, Nicholson & Eastin, LLP is here to help. Our experienced team is ready to provide comprehensive legal assistance tailored to your unique needs. Reach out to us today to schedule a consultation and take the first step toward resolving your concerns. Your legal solutions are just a message or call away.