If you do not know what ERISA stands for, then you are probably not aware that it is directly related to your ability to get paid for services you provide in a timely manner. You may also be unaware that, thanks to these five little letters, some of the major insurance carriers are in the fight of their lives ... and they're losing.
ERISA stands for the Employee Retirement Income Security Act. The regulation was enacted on Sept. 2, 1974 and signed into law by then-President Gerald Ford. It established the minimum standards for pension plans in the private industry and provides for all-encompassing rules on the federal income tax effects of transactions associated with employee benefit plans. Basically, it assists in the proper funding and oversight of public pension plans.
ERISA was enacted to protect the interests of employee benefit plan participants and their beneficiaries by requiring the disclosure to them of financial and other information concerning the plan. It does this by establishing standards of conduct for plan fiduciaries (overseer), and by providing for appropriate compensation and access to the federal courts. ERISA bypasses state court.
Are you asleep yet? Well, my friends, here is where it gets interesting. Because of its placement in the private sector, ERISA also regulates company-sponsored health insurance plans and the benefits contained therein.
The Chiropractic Angle
Now, you may still be asking, "What has all this got to do with me or even with chiropractic?" Well, ERISA directly controls what is covered by an individual's insurance plan. It is the final word. The final word is contained in the individual's Summary Plan Document. The SPD is the key to utilizing ERISA for your benefit and protection.
Consider the following example: You have a patient who has insurance XYZ. You call to verify benefits. The polite person on the other end of the line tells you that the individual has 20 allowed chiropractic visits per calendar year. They do not cover PT when performed by a chiropractor and they will pay a maximum of $40/visit. Does any of this sound familiar? Either you or your biller accepts this information and writes or copies it into the patient file. This then becomes "gospel" for the patient's file.
When the 20 visits are up, you sit and talk with the patient about the continuing need for care, and how their insurance won't cover any more visits and that they will now need to assume financial responsibility for their care. The patient then either chooses to continue or withdraws from treatment.
If you're still with me, hold on, because here is where ERISA, if you understand how it works, can flex its muscle to get all your patient's medically necessary care paid for. Let's start the process over again so we can clarify the differences.
Discovery
Your biller, before calling the insurance company to check for benefits, either collects themselves, or asks the patient to collect, a copy of their SPD from their human-resources manager at work.
They bring the large document to you. You take it home or better yet, train your biller how to read this document. You scroll down to the coverage determination and discover that in the SPD, there are no visit limits in the benefit plan.
Visits are shown to be based on medical necessity only. Also of interest, nowhere in the whole of the document does it specify who can perform physical therapy unless otherwise limited by their state license. So, what began as an average case now takes on a whole new meaning.
Now, your medically necessary treatment plan, including physical therapy and modalities, is a covered service. The most important part of all this is that there are no smoke and mirrors. The summary plan document is simply what your patient's employer purchased for their employee. In our current economy, people demand to receive the goods and services for which they have paid. This law (ERISA) and the document it requires does this for your patients.
Too Good to Be True?
Does this sound too good to be true? This is the type of knowledge chiropractors need to know, understand and utilize. This document protects us even further. How many of you are familiar with the dreaded "post-payment audit"? The cold chill that creeps up your back when the fax comes over requesting files for a routine file review? You diligently prepare and send the files, only to find out that a portion of your care wasn't medically necessary.
Don't worry though; you don't have to come up with the 300K today. They (the insurance company) will advise you to continue to see its members and it will simply deduct from your reimbursements until the overpayment is recouped.
[pb]Through ERISA, this type of behavior is being challenged as illegal, as we all know it is. Class-action lawsuits are being filed and won against the large insurance carriers who routinely bypass this law simply because they know most people, both doctors and patients, are ignorant of it.
This has allowed carriers to circumvent the rules for their benefit for years. State associations are now becoming directly involved. In fact, there is a class-action suit in process in Ohio involving some chiropractors and the Ohio State Chiropractic Association.
For more information on this suit and what you can do to help, visit the Ohio State Chiropractic Association Web site (www.osca.org) and www.erisaclaim.com. These and other resources can keep you up to date on the current struggles in which our profession is involved.
It's Not Just About Better Collections
In today's health care market, it is imperative that we at least become aware of the resources at our disposal, and assist those people and groups that are utilizing those resources to fight the battles that we cannot.
This is not simply to provide us with better collections, although fair payment for services is important. It is also for your patients. How many times have patients dropped out of care before their treatment plan was over, simply because they "ran out of benefits"? You did your due diligence, you offered them different payment options, but many people believe that if they have no insurance coverage anymore, then care is going to be too expensive; or worse, what if they believe that six or 12 visits are really all they need?
It still amazes me that this document has been around for as long as it has and yet, until I worked with an above-the-bar group of doctors in the Cincinnati area, I knew nothing about it. Maybe there are schools that instruct students in the finer points of being paid ethically. All I know is, mine did not. Every doctor needs to know about ERISA.
The Best Part
Now, here comes the absolute best part: This document is great for chiropractors no matter what their philosophical outlook is. If you accept third-party pay, this works for you. If your practice sees one hundred patient visits in a week, a thousand or, like the rest of us, somewhere in between, this law and the document that derives from it will increase your ethical profits starting now.
You don't need to pay a coach or marketing group. The truth is, the fees that this information will assist you in collecting were yours all along. It is your time now to reap the rewards if you only choose to accept responsibility.
Insurance Carriers Are Not Above the Law
We are learning that the large insurance carriers are not above the law. It will just continue to take a brave group of doctors to remind them of that fact. Big changes are coming to health care. Knowledge of the laws and rules that govern what we do and how we do it is information we can no longer afford to squander.
Our institutions of higher learning need to start teaching this now. We can no longer afford to rely on the "good will" of third-party payers, because let's face it: there's not much of that to go around.
It is time for us as a profession to take responsibility for collecting what we are truly worth in this new emerging health care market. We know that our care is valuable and worthy of reimbursement. Understanding and utilizing the laws and rules that are already in place prevent us from being taken advantage of and will continue to allow us to provide the life-saving and life-sustaining health services that are delivered in our offices every day.
Now, we can truly assist our patients in holding their insurance carriers accountable for making the coverage already purchased available to their members. I urge everyone to investigate ERISA and how it impacts your practice, and I urge you to do it today.
There is no "if" here. There is really nothing to think about. Trust me, it will be time well-spent. If you are interested in learning more, I will pen future articles on this subject.
This article was designed to introduce the unfamiliar to ERISA and how it can be used to enhance your individual patient's care, and how it is being used on a much larger stage to fight illegal and unfair practices that we chiropractors have had to contend with since being added to the current third- party system.
I never believed it before, but there are those in our profession fighting for all of us with no promise of reward beyond the satisfaction of helping a profession that has helped so many. Let's take advantage of their help. There is a great deal of knowledge out there to be utilized for our professional benefit if we will only take the time to stop, look and listen.
Resources used for this article include www.erisaclaim.com and www.erisa.gov.
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