|
|
WHEN INSURANCE COMPANIES UNFAIRLY DENY YOUR CLAIMS, MAKE THEM PAY!
By David Mullens, D.P.M., J.D.
If you are a PPO provider and are being denied payment by the insurance companies for your services, chances are those insurance companies are playing with fire. ERISA (The Employee Retirement Income Security Act of 1974) requires strict adherence by all insurance companies to the claims procedure regulations published by the U.S. Department of Labor. But most of the insurance companies have been ignoring these regulations, which have the force of federal law, and the penalties for the insurance companies’ noncompliance can be quite significant
In order to position yourself to take advantage of these ERISA regulations when an insurance company denies payment of a claim, you need to have an assignment that allows you to assert all of the patient’s rights against the insurance company for any ERISA violations. With a valid ERISA assignment you become the ERISA “beneficiary” and are entitled to payment for the insurance company’s ERISA violations. As an example, if an insurance company has a psychiatrist review your appeal of a denied foot surgery claim, an arbitrator or federal district court judge may award you up to $110 a day for each day from the time of your second appeal until the demand for arbitration is filed, or the complaint is filed in federal court. And there are many regulations like this one that may result in a large money award to the ERISA “beneficiary” when an insurance company ignores the ERISA claims procedure regulations.
The words in the “assignment” below have been chosen based on published federal district court cases. The attorneys in my law office have put in hundreds of hours of research and analysis on this issue. We hope you will choose to benefit from this effort.
THE GENERAL AND ASSISTANT SURGEON’S ASSIGNMENT FORMS FOR YOUR OFFICE
(The following is the general assignment you should have all of your patients, old and new, sign as they come in to be seen. This general assignment only has to be signed once. The ERISA portion of the assignment will allow us to pursue any insurance entity, other than Medicare and Medi-Cal, for payment of your denied claims in a more effective manner than is allowed under your State law provider contract, and will allow us to pursue these insurance companies for any ERISA claims procedures violations.).
|
I assign the right to payment for all medical benefits directly to (names of all the doctors in the practice) in consideration for medical services and supplies provided pursuant to my health insurance plan.
In the event my health insurance plan refuses to pay for provided, medically necessary services, I also assign all my ERISA* rights to (names of al the doctors in the practice) for a full and fair review of any and all denied claims. This ERISA assignment is in consideration for the unpaid services provided and in consideration for the continued willingness of (names of all the doctors in the practice) to see patients, including myself, on an insurance assignment basis. I understand that if my treating doctor prevails in any such payment dispute, I may be liable for co-payment for the contested services.
I give consent to release medical information to (names of all the doctors in the practice). I give consent to (names of all the doctors in the practice) to release medical information to other healthcare providers for the purpose of treatment, when necessary for my care. I give consent to (names of all the doctors in the practice) to send medical information, as necessary, to my insurance plan.
*ERISA is an acronym for the Employee Retirement Income Security Act. The Employee Retirement Income Security Act includes federal laws requiring insurance companies to process submitted insurance claims and appealed (denied) insurance claims according to ERISA regulations. The failure to process submitted insurance claims and appealed (denied) insurance claims according to ERISA regulations may result in fines charged to the insurance company in amounts up to $110 a day for each infraction.
Patient’s printed name __________________________________
Patient’s signature_________________________________
Date_________________
|
(You should use the following SEPARATE assignment for assistant surgeon’s services).
|
I understand Dr. ________________ will assist at my surgery, and in consideration for receiving medical services provided pursuant to my health insurance policy, I assign payment of my insurance benefits directly to the assistant surgeon for the assistant surgeon’s services provided.
In the event that my health insurance plan refuses to pay for medically necessary assistant surgeon services, I also assign all my ERISA* rights to a full and fair review process to the assistant surgeon named above for any and all denied assistant surgeon’s claims. In consideration for this ERISA assignment, the assistant surgeon agrees to potential non-payment and/or undertaking responsibility for the denial determination appeal process under the terms of my health care plan. I understand that if the assistant surgeon prevails in any such payment dispute, I may be liable for co-payment for the contested services.
*ERISA is an acronym for the Employee Retirement Income Security Act. The Employee Retirement Income Security Act includes federal laws requiring insurance companies to process submitted insurance claims and appealed (denied) insurance claims according to ERISA regulations. The failure to process submitted insurance claims and appealed (denied) insurance claims according to ERISA regulations may result in fines charged to the insurance company in amounts up to $110 a day for each infraction.
Patient’s printed name __________________________________
Patient’s signature_________________________________
Date_________________
|
Please email me at dmullens@mullenslawoffice.com if you have any questions as to how to use this assignment form.
Disclaimer: Information contained in this newsletter does not constitute legal advice and is not a substitute for the professional judgment of an attorney.
Back to Articles & News
Join our mailing list
|
