February 10th, 2015
Several years ago, a landmark federal court ruling was made regarding ERISA appeal rights. In the case of "Pennsylvania Chiropractic Association v BlueCross BlueShield Association," the court made a summary judgment against the defendants (BCBS) on the following issues:
- “Entitlement to ERISA notice and appeal rights”;
- “Adverse benefit determination”
- “Appeal rights”
- “Authorized representative”
The following articles give more information about this particular case:
- Chiropractic vs BCBS
- Federal District Court Rules in Favor of Chiropractic
- In Case You Missed It: Plan Administrator Must Give Providers ERISA Appeal Process
Since that time, ERISA lawsuits have continued to be filed with most being ruled in favor of providers seeking relief through the court system. On March 28, 2014, yet another ERISA lawsuit against Independence Blue Cross (IBC) once again upheld a providers rights under ERISA. According to the court’s opinion, the insurer’s “practices come nowhere near substantial compliance with ERISA’s notice and appeal requirement.” Click here to read a detailed report on that ruling.
Even though significant changes are happening in this area, healthcare offices need to take a pro-active approach to verification of coverage. With all the changes in health plan coverage since the implementation of the new healthcare laws, verification of insurance coverage has become a more critical function for your practice. See the ChiroCode DeskBook for more information about verification of insurance coverage.