ERISA and Health Insurance Audits
The Employee Retirement Income Security Act, 29 U.S.C. § 1001 et seq., commonly referred to as ERISA, is a federal law that was enacted to protect the interests of employees and their family members who are enrolled in employee health benefit plans. When a claim for benefits is received by an employer sponsored health plan, the plan or the plan administrator must strictly adhere to the ERISA claims procedures regulations when it processes and pays the claim. These standards apply to pre-payment claims and post-payment claims. When a plan or a plan administrator (e.g. the insurance company) denies payment for a claim, it must strictly comply with ERISA; otherwise, ERISA provides statutory remedies for the member/beneficiary.
Healthcare providers can benefit from ERISA. When an insurance payer denies payment on certain types of claims submitted by the provider on behalf of the member/beneficiary, the provider may be able to pursue the same remedies. ERISA is a powerful statute that can help providers who are facing an audit or recoupment. ERISA is very complex and the federal courts are consistently interpreting the law in the context of insurance post payment audits. The healthcare attorneys at The Martin Law Firm, P.C. closely monitor federal court ERISA opinions in order to be qualified to defend an audit or recoupment effort on your behalf.
Contact the Martin Law Firm, P.C.
If you are a healthcare provider facing an audit or recoupment from an insurance payer, ERISA may provide you with a tool for fighting back. Contact the healthcare attorneys at The Martin Law Firm, P.C. to discuss your situation and we can assess whether we can use our skill and expertise to help you.