ERISA plans still cause high frustration for providers at contracting, patient access, registration and revenue management touchpoints. Here's why:

What the heck is ERISA anyway?

The Employee Retirement Income Security Act of 1974 ("ERISA") is a federal United States tax and labor law that establishes minimum standards for pension plans in private industry. But it also has a big impact on employee and labor union healthcare benefits for active employees and retirees and dependents of those employees and retirees working at over 210,000 companies and labor unions that operate self-funded health benefit plans in the USA.

N.B. (1/4/2018) - Today, President Donald Trump proposed new rules to make it easier for small businesses and individuals to purchase association health plans - that could preempt some of the insurance protections revenue management and contracting staff expect when trying to collect on claims for patient services. Opponents fear that unchecked, these plans could promote illusory or substandard coverage in the marketplace. Association plans would become available to individuals for the first time. And in a significant change, it would classify such plans the same way as large employers’ self-funded health benefit plans under ERISA, which means that they would no longer have to include a set of 10 essential health benefits that the ACA requires of insurance sold to individuals and small companies. Complaints about association health plans may be subject to the ERISA rules, processes, tactics and strategies that are the subject of this article. the Labor Department predicted that up to 11 million currently uninsured Americans who work for small businesses or are self-employed could benefit from the expansion of association health plans. This new change means that the value of learning how to better deal with ERISA and Taft Hartley plans is increasingly significant for healthcare providers.

Which contracts are involved?

In preferred provider organization ("PPO") contracts, the number of corporate sponsored, self-funded health benefit plans accessing discount payment rates negotiated through a PPO is largely made up of ERISA and Taft Hartley plan sponsors who don't pay insurance premiums to the insurance plan whose logo is shown on a patient's identification card. But they also show up in "all payer" or "all products" contracts, and in HMO contracts where the HMO operates an ASO as well.

Instead, the self-funded employer plan sponsor or labor union health and welfare plan simply "rents" the contracted provider network and is authorized to pay the negotiated discount PPO rate instead of full, retail billed charges. To do this, in most cases, the plan sponsors pay a "network access fee", per-employee, per-month. Sometimes, instead of the PEPM fee, they buy the discount for a percentage of the savings on a single claim on a one-off basis.

A big challenge for contract analysts, revenue management and patient registration personnel is that most haven't been adequately trained how to spot these plans, what the rules are, how to enforce the rules, and how to resolve future payment SNAFUs with effective tactics and get paid with fewer hassles. As a result, billions of dollars in care that should be paid for are either paid late, slow or not at all.

ERISA was enacted to protect the interests of employee benefit plan participants and their beneficiaries by:

• Requiring the disclosure within a specific time frame of financial and other information upon a proper written request concerning the plan benefits, claim payment rules and payment limitations to beneficiaries (and their "Authorized Representatives");
• Establishing standards of conduct including the responses to these written requests for plan fiduciaries;
• Providing for appropriate remedies and access to the federal courts and authorities such as the IRS when these claims are not processed properly or enforcement falls outside the jurisdiction of state insurance regulators.

The huge misconnect

It is caused by the lack of understanding that the healthcare providers and their contract analysts, revenue management and patient access and registration folks have regarding "why they should care" about a law that is designed to " protect the interests of employee benefit plan participants and their beneficiaries".

Here's why they should care: They want to get paid. To do so, they need to know how to fight claim payment delays, wrongful denials of healthcare benefits, whom to fight with, what documentation to have ready, and what to say or write in order to cause a check to appear in the lock box.

SELF TEST:

How often has this occurred?

You've negotiated a lengthy PPO or HMO contract full of rules, mandates for administrative write offs, and other performance requirements. You've done your best to follow every rule and you still haven't been paid according to what the contract specified. When you try to solve the problem, you are told, “We’re an ERISA plan, all those rules don’t apply to us.” You hear the resistance/excuse/blow off but you aren't sure if there's a way to push back and the person on the other end of the phone isn't about to teach you what you should do to get paid.

If you work in the business office, you move down the list to the next claim and see if that works any easier. You view your role as "get it paid". You are graded on the number of dollars you bring in; not how valiantly you fight to get paid.

Meanwhile, that claim languishes in the organization's A/R for a few months until someone downline marks it an " insurance denial" and inappropriately transfers the balance to patient's self-pay ledger and starts sending bills to the patient for the full balance due. That upsets the patient who calls and asks why they are getting a bill. They explain that they have (or had) insurance and to bill their insurance. Your staff states "We did and they refused to pay the claim, so we sent the bill to you." The patient continues to ignore the bill, no cash comes to the provider, and the balance is then sent off to an outside collection agency, who wrongfully ruins the credit of the patient.

The provider still hasn't been paid, a patient is no longer a brand advocate, and the patient files bankruptcy and the hospital still doesn't get paid.

What's the materiality of the problem?

I would venture an educated guess after more than 35 years in the business that 95% of PPO claims in your aged trial balance at 61+ days are ERISA claims that are improperly handled for a number of reasons.

All reasons lead to one culprit: lack of training and know how. But here's the biggest tragedy: If the team isn't sure what the heck ERISA is or why they should care, they aren't likely to ask for training to fill the knowledge gap.

If you could eliminate these problems entirely, and only have to deal with the frustrating situations where the self-funded health benefit plan is declared insolvent or is guilty of bad faith in refusing to paying the claim, would you do it?

For 2018, I've developed an ERISA process improvement training workshop designed to split the hospital contract analysts and negotiators, revenue management staff and registration staff into two groups. This program explains the defensive tactics and strategies necessary to eradicate these problems associated with ERISA contracting, payment recovery once and for all. I cover 35 separate but related touchpoints that can be addressed internally without further consulting fees stop these problems from recurring once and for all.

It makes no difference to me if you invite the independent (non-employed) medical staff office managers, billing and collections staff and front desk personnel - the more the merrier! Just charge them a small, pro-rated, per practice fee to attend and cover their costs for a catered lunch and refreshment breaks so you don't get in trouble on the anti-kickback compliance rules.

For one flat fee for the 2 days of training, you get one master digital copy of all handouts that can be sent to each attendee via email so you don't have to print and prepare copies. The same program is repeated each day so that you can divide up the personnel and each group gets the same training. The benefit of training the entire team in a single group comprised of managers, contract analysts and negotiators, revenue management, and front end is that they will all leave with a complete understanding of all the touchpoints in the process and know how to help one another to be more effective from one end of the process to the other.

The flat fee includes my travel and local hotel accommodation. Each day, the training runs from 9am until 3:30pm. In addition to the flat fee for my travel and training, you provide the training venue and audiovisual equipment, event organization, catering, and registration. I'll even supply a Certificate of Completion so that each participant has a record of the training for their personnel file. For those who book dates before January 31st, 2018, I will add one additional bonus: A 90-minute, follow up Q&A web conference 60 days after the event where every participant can listen in and submit any questions or submit problems they want guidance on after the training at no additional charge.

According to the American Hospital Association there are more than 5000 registered hospitals in the USA. But I can only accommodate 25 hospitals and health systems in a year. Will you be one of them?

To get started, decide on a few dates you'd like to check my availability. Then call my office (800) 727.4160 and let's get it on the calendar.

There isn't a hospital, clinic or ambulatory surgery center, a diagnostic imaging or lab group, DME, physical or occupational therapy, or an addiction treatment center in the USA that I've encountered in all my years of consulting and training that doesn't need this training. Let's make 2018 the year we overcome this brutally frustrating and costly problem once and for all.