Celebrating 10 years! 2007-2017

Case involves ERISA, I am clueless.

Hospital rendered care to participant. Hospital accepted pay vohod04/09/17
Sounds like they are stuck in reference to collecting from t therewillbeblood04/09/17
Thanks! vohod04/09/17
Not sure why this is an ERISA issue. All employee health pla onehell04/10/17
Thanks. I asked for their agreement with this carrier early vohod04/10/17
vohod (Apr 9, 2017 - 3:37 pm)

Hospital rendered care to participant. Hospital accepted payment under a health plan governed by ERISA in 2015. Evidently the participant's counsel advised Hospital to appeal if it wasn't happy with what was paid. Hospital never appealed but the plan paid 28% of a claim in excess of $250,000. Counsel has told Hospital they lost any right to collect on this by failing to appeal under the plan.

Now I have to deal with this. I am not familiar with the statute yet but plan to research it more today and tonight. My gut is to tell the Hospital they are stuck and need to close it out. Anyone had any success actually recovering anything in these circumstances?

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therewillbeblood (Apr 9, 2017 - 5:01 pm)

Sounds like they are stuck in reference to collecting from the Plan, because absent any sort of contractual agreement saying otherwise the Plan's obligations are to the participant -- plan documents bind the plan, the participant, and the settlor, but absent any contractual agreement otherwise not the hospital or the plan in relation to the hospital. It sounds weird to me that participant's counsel was telling the hospital to appeal; the hospital should have just billed the participant the overage and let the participant appeal to the plan.

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vohod (Apr 9, 2017 - 5:17 pm)

Thanks!

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onehell (Apr 10, 2017 - 2:47 pm)

Not sure why this is an ERISA issue. All employee health plans are ERISA plans, yes, but the interaction between provider and insurer is more along the lines of straight-up contract law.

Is hospital in the insurance company's network? If yes, then hospital signed a contract with the insurance company and is bound by its terms, which you would have to review in order to opine. And yes, it is true that most such contracts will have a dispute resolution clause that creates an appeal process which providers must abide. The contracts also set forth what the rate for various services is, the billed charge is irrelevant: They can only charge what they agreed to be paid, whether to the patient or to the insurer.

If, OTOH, hospital does NOT have a contract with the insurer then they can pursue the patient directly for whatever their chargemaster rate is, which may be a case of trying to squeeze blood from a stone but most do try. Also, if the hospital is a nonprofit, they are supposed to review the patient's circumstances to see if they qualify under the hospital's financial assistance policy before engaging in "extraordinary collection efforts" such as suing or referring the bill to collections. This is an ACA requirement.

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vohod (Apr 10, 2017 - 4:15 pm)

Thanks. I asked for their agreement with this carrier early this AM. I am also aware of the 501r stuff and the patient did receive the plain language summary. I really appreciate this post.

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