ERISA Recovery

The Employee Retirement Income Security Act (ERISA) became a law in 1974 to protect pension plans in private industry, but its regulatory scope has expanded to healthcare. Today, ERISA is considered the most powerful appeals method for commercial claims that have been denied or underpaid. Experts at Elevate Medical Solutions’ ERISA Commercial Claims Recovery will help you to maximize the reimbursements you’re properly due. We’ll handle your appeals quickly and increase your revenue.

Examples of Recent ERISA Denial Successes:

• $1.2 million recovered for an in-network New York hospital that was denied the use of Alloderm for breast reconstruction surgery.

The health plan denied 250 claims, asserting Alloderm was “experimental/investigational.” ERISA appeals based on the Women’s Cancer Rights Act, language from the employer’s Summary Plan Description, and the health plan’s own internal policy resulted in full reimbursement.

• $350,000 recovered for an in-network Wisconsin hospital denied for emergency implantation of a pacemaker.

The health plan denied the claim as “medically unnecessary,” and a first appeal was denied by an OB/GYN registered nurse. The ERISA appeal cited violations based on the appeal review of a cardiac case by an OB/GYN registered nurse.

• $1 million recovered for an out-of-network implantable device supplier.

A health plan denied numerous claims asserting that out-of-network implantable devices were an “excluded/non-covered” service. ERISA appeals efforts reviewed Summary Plan Descriptions from several employers involved—none precluded out-of-network implantable device suppliers from billing for their services.

• $750,000 recovered both for anesthesia services provided by a CRNA and for the use of Propofol.

A health plan denied several claims over two years asserting that the CRNA’s services were not covered under a state employer-based plan. The ERISA appeal proved that the Summary Plan Description did not exclude services rendered by a CRNA nor did it exclude Propofol.

ERISA is a very complicated process for appeals but can be well worth the effort with a high ROI. If your current appeals process is not yielding the results that you want and deserve, you should consider engaging an expert in ERISA for your appeals. Elevate Medical Solutions' ERISA Recovery Experts are ready to help you earn what you are allowed under appeals. Elevate your ERISA recovery – it will be worth your efforts.