After reviewing the claim and the provider attorney letter, USB felt the best next step was to engage an ERISA attorney.
At USBenefits, we bring experience, professionalism and unmatched customer service to every interaction. Your goal is our goal – to provide the best possible outcome for the employer. To ensure that happens, we prioritize leveraging our resources to navigate you through your unique claim situations.
Our three-part Claim Success series was a hit – but we’re not done yet. Check out another recent success story achieved by our claims team.
USBenefits received a very urgent email from a broker regarding an attorney letter from a provider. The provider was threatening the Plan with a lawsuit for what the provider stated was “an unpaid balance on a claim that was over a year and a half old.” The broker was concerned that if the Plan had to pay additional money on the claim, that it would not be covered by the USB stop loss contract (that had expired).
The claim had been paid by the TPA based on the Plan document language indicating a payment of 140% of Medicare. The billed amount was $420,000 for a seven-day inpatient stay. Even though the claim was never sent to USB for reimbursement because the payment did not exceed the Plan specific deductible, USB staff was more than willing to review the claim for our partner TPA.
After reviewing the claim and the provider attorney letter, USB felt the best next step was to engage an ERISA attorney. After a thorough review, and discussions with USB and the TPA, the ERISA attorney sent a letter to the provider’s attorney. The letter outlined the Plan document language regarding claim payment and pointed out the appeal guidelines in the Plan.
The result? After not receiving a response from the provider’s attorney and sending multiple follow ups over the next several months, the case was considered closed.
USBenefits has access to the top legal and cost containment vendors in the Self-Insured industry, and we’re always willing to step in and help our TPA partners/Plans with any issue that may come up. Be sure to subscribe to our emails and follow us on LinkedIn so you don’t miss out on our next Claim Success story.
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