Frequently Asked Questions
CRC offers, as a unique outside service, a process to appeal bad debt insurance claims (back through January 1, 2003) under federal ERISA law as a patient advocate. ERISA law defines a healthcare denial as “anything less than 100% payment of the claim”, meaning full charges (not the PPO amount). This has the potential to deliver substantial portions of the contractuals for any claim where the commercial insurance coverage was issued by an employer (government, church and a few other minor categories are excepted). CRC performs this “administrative appeal” process with no upfront fees and is paid a percentage of new payments delivered directly to the hospital. CRC’s staff performs all work and answers all correspondence. CRC’s approach has been utilized by hospitals and other providers for over ten years and they have clients from California to New York.
Q: “Is CRC a collection agency?”
A: No. We never ask a patient for money. Any patient portions are left to your accounts department. CRC appeals the contractual or other unpaid portions of insurance company amounts due utilizing federal ERISA law as the basis for the appeal.
Q: “Why do you contact our patient”?
A: Under ERISA, providers do not have automatic appeal rights, regardless of PPO/MHO/MCO participation status, to challenge the plan’s delay or denial of your claims, therefore, CRC will contact previously treated patients and obtain, where possible, a perfected “legal assignment of benefits” for authorized representative in the name of the client. The plan will then be required to provide benefit determinations and other notifications to the authorized representative, both claimants and plans understand and make clear the extent to which an authorized representative will be acting on behalf of the claimant based on CRC’s communications process.
Q: “Will the insurance companies retaliate”?
A: These are matters of federal ERISA law and no honest company seeks to operate outside the law. Further, within ERISA resides USC1140/1141, laws specifically prohibiting the use of coercion or intimidation in the application of ERISA.
Q: “Will the employers be angry at the hospital”?
A: Our actual experience demonstrates that most employers do not realize that there has been a potential violation of law in the processing of their employees claims for benefits and appreciate that compliance is vitally important to their business. Further, once an employer finds that the employee is in real financial jeopardy because the benefit promised (i.e. “80 %”) has been paid at a level other than the promise, they seem eager to assist their employee.
Q: “Will you push us into court and cause us high fees”?
A: We never take a case to Federal District Court ourselves. In cases where we believe this action is warranted, we have made arrangements with several experienced ERISA specialized law firms to engage with our clients directly on a “contingency fee basis”. We are prepared to demonstrate how working cooperatively, You, CRC and the law firm can each contribute to a fee arrangement that makes sense to proceed.
Q: “Do you receive the additional funds or do we”?
A: All monies will be sent directly to client as per their normal lock box procedure and CRC will be paid as a vendor according to a fully executed contract only after funds have been deposited in to clients’ accounts.
Q: “How are you different than another company we use”?
A: We do not involve our special appeal process with billing, coding or other clerical reviews. We have no “super software” that can ‘scrub’ of ‘fix’ your claims. We analyze and construct ERISA compliant appeals utilizing highly trained personnel who design an individual approach to each EOB separately. We do ERISA only, every day.
Further, there are some “PPO Check” type companies whose service is to “check off” that they “verified” that an EOB “paid per the terms of your discount provider contract”. CRC might take the same claim and file an ERISA appeal for 100% of charges. The difference here is dramatic; we will collect on many EOB’s where these other companies will pass them over, and often at full charges.
Q: “Why are our lawyers not familiar with this”?
A: ERISA was passed in 1974 and is generally regarded as “employment law” not “healthcare law”. Our ERISA specialized legal colleagues tell us that ERISA law is not much emphasized in most law schools except via electives. Many attorneys believe that contract law is adequate to resolve any payment disputes in healthcare as there are nearly always contracts in place, however, federal law, as unanimously decided by the U.S. Supreme Court in Aetna v. Davila, supersedes any state law or contract provisions in this arena.
The EBIA (Employer Benefits Institute of America) held a webinar with two ERISA attorneys instructing members what to do about ERISA based claims. Their slides from the seminar are available and from our view, they support in each step, our appeal process and affirm their responsibility to comply with the law.
Clients have vetted us through ERISA specializing law firms and state Hospital Associations who have affirmed our statements of ERISA law. We are pleased to co-operate in any vetting scenario
Q: “Why do you request an exclusive arrangement”?
A: We do not require an exclusive engagement other than the assurance that we will be the only party working on a particular file at any given time. This is to avoid any confusion concerning whose work effort produced a given result.
Q: “How do you arrive at your fees”?
A: Given that our appeals process begins with “zero balance” accounts that are completely inactive, our work based on federal law that is unique and requires specially trained personnel and that we provide our service utilizing our own resources with no upfront cost where the resulting new revenue will take several months to reach our accounts, our fees are actually a fair reflection of the value delivered.