Ep. 25: Discover the most important, unused way to appeal claims with Don Self

This could be the most important episode you listen to if you own a physician practice or do their billing.  In this installment of the Surviving Healthcare podcast, you will hear a discussion of the far-reaching impact of the Employee Retirement Income Security Act of 1974 (ERISA) when it comes to insurance and physician and practice reimbursement. My guest for this episode is Don Self, who is a medical reimbursement consultant with 28 years' experience assisting physicians with reimbursement issues. He has written several books on reimbursement and has a brand new one that will be out later this year.

 

You'll hear how ERISA is a federal labor law and how it applies to the vast majority of insurance claims. Physicians will be interested in learning how the law can help them avoid being railroaded by insurance companies, especially when they demand money back from a physician or deny a claim.

 

We then talk about which claims ERISA applies to and Don explains why everyone needs to understand that the claim doesn't belong to the insurance company or the physician or hospital, but to the patient.  Understanding that an insurance policy is a contract between the insurer and the insured is paramount.

 

Don notes that too many physicians have no idea that they can fight a reimbursement claim made by an insurance company, which is when we talk about the difference between appeals and grievances and how each is handled. Most people believe they have been through the appeals process, even though they haven't. He also notes that the distinction is important, because insurance companies are not required to respond to grievances.

 

Don gives physicians advice on handling disputes by using specific language to save physicians when insurance companies demand a claim repayment. This discussion also includes what happens when an insurance company down codes a claim, and why understanding the process and following up by matching CPT codes with their records is important for keeping carriers from employing deceptive practices.

 

You will also hear a discussion of who physicians and billers should talk to at insurance companies to get things done when filing an appeal.  The advantage of skipping the claims department and going directly to the legal department when ERISA is involved.

 

We close our discussion with Don offering advice to physicians on how to use ERISA to save their practice a lot of money.  No one should walk around ignorant about this issue. ERISA can be a doctor's best friend and give them the money they are rightfully owed from insurance companies.

 

To read more about this episode or check out other guests and topics, visit surivivinghealthcarepodcast.com