ERISA Health Plan Claims Update: Claims Review Poised To Change

On September 29, 2022, the U.S. House of Representatives approved passage of the Employee and Retiree Access to Justice Act, a bill that if enacted into law has significant implications for providers seeking payment of health plan claims governed by the Employee Retirement Income Security Act, commonly known as ERISA.

Currently, ERISA authorizes benefit plan sponsors to keep for themselves discretionary authority in claims determinations.  This has historically limited the ability of courts and judges to overturn claim denials that have been upheld by benefit plans during the administrative appeals process, effectively upholding the denial of otherwise legitimately payable claims.  If codified into law, the Employee and Retiree Access to Justice Act will authorize courts and judges to review claims determinations “de novo” – a legal term meaning from the beginning and anew – which will have the effect of giving medical providers greater leverage in claims processing and challenging payment denials.

On October 11, 2022, the Employee and Retiree Access to Justice Act was received by the U.S. Senate, where it was referred to the Committee on Health, Education, Labor, and Pensions.  Miller Johnson’s #MedRecovery team will continue to monitor this legislation that, if passed, promises to facilitate claims payments to medical providers from health plans governed by ERISA.

If you have questions about this or any other medical reimbursement issue, please contact Joseph Gavin or any one of our provider reimbursement counsel at mjmedrecovery.com