Claims and Appeals Traps and Pitfalls – Avoid the Landmines Inherent in the Process – The claims and appeals process is the bedrock of health plan administration.  It is the process that ensures both the claimant’s and the plan’s rights are protected. Consequently, the process is heavily regulated by the agencies. A faulty process cannot only lead to litigation by claimants or providers against the plan but can result in costly investigations by the Department of Labor and even IRS excise taxes.  Is your process defensible?  In this session we will address the following topics to help you evaluate your claims and appeal process and avoid the traps:

• Plan document language – Plan document language is key not only to a compliant process but also supporting a defense in the event of (inevitable) litigation.
• The claim and appeal filing process – What is required for a claimant to file a claim? An appeal? Are there any unreasonable impediments?
• The review – Does your process provide a “full and fair review” as contemplated by ERISA and the courts? What is required for a “full and fair review”?
• Authorized representatives – What steps must a claimant take to authorize a third party to file claims?
• Notices of adverse benefit determinations – Do the notices adequately inform claimants of the decision, including the underlying basis for the decision?  Does it give adequate descriptions of what it takes to perfect an appeal? Is the plan document/SPD cited?
• Interactions with providers – how does your process handle “claims and appeals”? Does the plan have an anti-assignment clause?
• So much more……….