One of the leading legal publications on the web sat down with our firm to discuss the use of ERISA — the employee benefits law — in fighting back against health insurance companies and health plans. Many doctors and medical practices are not aware that their patients hold valuable rights under their health plans that can be used by these medical providers. These rights include access to information from the health insurers and the right to declare various health insurer practices and conduct as unlawful. According to our partner, these tools are essential in fighting back against audits and in obtaining payment on denied claims.
Below is the text of the article and the interview:
Monday, October 1, 2012 by Jonathan Shub
Alex Levin is a writer for Seeger Weiss LLP, a top ranking law Plaintiff’s law firm specializing in injury cases, consumer protection, and commercial disputes.
The vulnerable world of employee health benefits has seen a great deal of fluctuation since its inception, to the point where employers, employees, and medical practitioners are all so swamped with information that the important pieces can get lost in the cracks. But information is the name of the game when it comes to health insurance, with even professionals getting lost in this murky world (and certainly the layman).
The Employment Retirement Income Security Act of 1974, or ERISA, is one useful federal law, because it is intended to provide protection to many of the nation’s employees. Although it does not compel employers to adopt a pension plan, by establishing minimal guidelines for employee benefit plans (such as retirement pension plans), it gives employers the information they need to offer a suitable one. And as for the employees or the medical practitioners, ERISA ensures that they are both informed and legally equipped in their access to minimal health benefits, if any are to be offered.
This law, while having its basis in the President’s Committee on Corporate Pension Plans established by President John F. Kennedy in the early 1960s, adopted its current form as a result of a 1972 NBC television program called Pensions: The Broken Promise which exposed millions of Americans to horror stories about lax health care and the inadequate funding responsible for it. Within two years of the TV show, with the public pushing congress and congress pushing the white house, President Gerald Ford passed ERISA on September 2nd, Labor Day.
Since then ERISA has undergone many changes, but one of the most pertinent features to those of us living in the information age is the commitment it fosters among employers to keep their employees in the know when it comes to their benefits, and so decreasing the chances of mistake or neglect based on ignorance. However, to be an effective source of information, as the act offers to be, one must first be aware of the source.
Our partner has in the past contributed to Lawyers.com, Forbes.com and Business Insider, amongst others, and he believes that employers have a right to be as informed when it comes to the ERISA law that affects them as do their employees. More to the point, our partner knows it is in their interest, having this year alone been involved in millions of dollars- worth of settlement disputes based on this law.
Please give a brief description of what ERISA is for those who may not be familiar with it? It is a federal law that governs all employee benefits, such as health insurance and health plans, disability insurance and disability plans, life insurance and plans, and various types of pensions.
What is the history of ERISA and its various iterations?
It was originally proposed in 1972 to address problems with the handling of employee pension funds. Prior to its enactment, it was expanded to include all employee benefit plans. Since its passing, employers need to comply with various rules that ensures disclosure to the employees, while providing important planning documents to their employees, among other things.
How can medical practices take advantage of ERISA?
The patients of health care providers are often covered under health plans they obtain at work; these are legally considered employee sponsored health plans, governed by ERISA, whether they are fully insured by a group insurance policy or self funded by the employers. When the employee or his or her family member that is covered under the plan assigns their health plan rights to the health care provider, the health provider / medical practice can then use the many important tools and exercise the many rights under ERISA that the patient has under the law.
What are the most crucial parts of ERISA to understand?
The health plan or insurance company handling claims must comply with special rules as to the timing of their decisions on claims and must explain any negative claim decision, in detail. The employee or the health care provider — by way of the assignment — is also entitled to a vast array of information from the entity that has denied or only partially paid a claim, such as medical opinions, emails, company guidelines, notes, and other information that sheds light on the claim decision.
Why do you think certain employers or medical practices haven’t been taking advantage of it?
I believe that the medical practices are overwhelmed with so many laws and rules regarding their practice and that they have not been properly informed as to how all of these ERISA rules can be used to protect their income.
How can a lawyer such as yourself help tackle ERISA?
We use it every day to help doctors and all health care providers to avoid audits, to reverse health insurers’ efforts to attempt to obtain refunds of money already paid on claims, to pursue collection on groups of denied claims, and to ensure payment on ongoing and future claims. We also use decades of insurance claim and litigation laws and rules, in conjunction with ERISA, to make sure that the rights of medical practices and all health care providers are protected as to claims previously paid and on current or unpaid / denied claims.
Evan S. Schwartz
Founder of Schwartz, Conroy & Hack