Employer ERISA Claims Review

Employers ERISA recovery claims

 

Recovering Medical Denials and Overpayments for Employers

The ARC system of companies includes two of the nation’s top specialist firms involved in recovery of adverse (denied or disputed) medical insurance claims.

This business arena is highly regulated and litigious. And, to be frank, you must win – there are no prizes for those who come in second place.

 

You Should Know

  1. ARC affiliates regularly handle account sizes varying from 250 to 50,000+ employees. ARC services are sufficiently cost-effective for the 100 to 250 range and are being extended to the 50 to 100 employee range.
  2. ARC has existing capacity for doubling its client base, and is aggressively positioning itself to handle massive client growth. This growth is prerequisite to ARC’s vision of a fair and honest healthcare system for American workers.

 

ARC provides three key services to an employer that, in our experience, has given employers greater employee satisfaction and wellness, plus measurable improvements in corporate financial stability and thrift.

  1. ERISA appeals recovery of denied medical claims and insurance overpayments.
    • Recoverable amounts can be large.
    • Caveat Emptor – use of a less experienced recovery specialist carries risk, e.g. longer, costlier litigation, fewer successful judgments and lower awarded amounts.
  2. Auditing of certified plan design
  • Ready employers for full auditing by the DOL Office of Inspector General.
  • Identify structural gaps in health plans and clarify their efficient resolution.
  1. Certified QHWBP design
  • Design of certified qualified health and welfare benefit plans –
  • At low cost, fully transportable and reproducible, with full item-level cost transparency.
  • Compliant to PPACA and ERISA, often in real time.

 

What separates ARC employer services from those of other firms? ARC has a superior package of deep expertise, and a track record and philosophical approach to good business that is simply second to none.

ARC emphasizes three words in their unique approach: plan transparency, reproducibility and portability:

  1. Transparency refers to transparency of item-level costs – no more contracts that prevent employers and providers from seeing what each pays. Transparency provides a foundation for trust and clear communication, and thus for customer service, as well as confidence that ARC services provide outstanding value for money.
  2. Reproducibility refers to repeatability of costings. Presently the reimbursable costs for a, say, a basic knee replacement vary by insurer and provider. With ARC, reproducibility means this surgery is reimbursed with a fixed amount, each and every time. How does this help you? Employers no longer have to over-insure themselves to accommodate unexpectedly high medical charges.
  3. Portability ensures convenience. ARC health plans are transportable between all US states, e.g. a traveling employee is always covered. ARC even has ex-pat plans to meet the needs of US multinational firms. It also means that concerns about being “in” or “out” of network, and associated inability of patients to access superior healthcare, is a thing of the past.

 

For many employers, recovery (see Box) is particularly attractive because the sums can be large. By law, recovered funds must be held in trust for employees; still, this means significant future savings to the employer. Some companies that win large recoupments become proactive in healthcare, e.g. providing employee wellness programs. ARC’s billing policy is to bill you only after you have received a recovered settlement. And many cases are settled out of court, often for multiple-times damages.

“Recoupment”

Recoupment is industry jargon for identification and recovery of insurance claims that were overpaid or not fully reimbursed to the self-funded employer (and typically denied or underpaid to the medical services provider, as well).   Recoupment recaptures money owed to employees for their health benefits. Recoupment also sends a clear ‘signal’ that an employer is responsible and is taking care of the well-being of its employees.

 

Employers and ERISA Compliance

Many employers have heard that they are not responsible for ERISA. Wrong

A common misunderstanding relates to who is responsible for preparing, filing, and delivering SPDs and Form 5500s. Many employers believe that their insurance broker, insurance carrier, accountant, or lawyer takes care of compliance responsibilities, particularly if they are fully insured (in contrast to being self-funded).

In fact, ERISA compliance is normally solely the employer’s responsibility, regardless how a QHWBP is funded. This is true regardless of employer size or number of employees – ERISA is the law, and is federal law that preempts (trumps) state law

There are very few exceptions to ERISA’s applicability to employers. Yet, available statistics suggest that many employers would fail a critical ERISA audit of their health plans

Don’t be a statistic. There is only one smart approach to compliance – become compliant before your audit. ARC can audit your firm, identify any compliance gaps and give you specific steps to action to ready yourself to withstand a DOL audit

Register for your free consultation (Hyperlink to register) or email ARC at info@arcrecovery.com and we will have one of our agents contact you