Thank you to Don Self from   Don is the GO TO person for learning about ERISA. Even with my almost 30 years in the industry, Don has taught me so much about ERISA and how it affects medical billers and practice managers!

Author: Don Self

Posted with permission:


Let’s talk about how to handle a retroactive denial (also called an adverse benefit determination). Most people working in physician offices think that the reason the carrier is asking for money back determines whether the doctor or hospital should write a check back from the carriers. The carriers WANT you to think that!

Let me explain. It does not matter WHY the carrier is demanding money back from the doctor. In 2002 The US Supreme Court ruled that insurance company’s must recoup from the patient.  In March of 2014 Blue Cross Blue Shield was named in a suit;  PCA v BCBSA  and settled in court in March of 2014 for more than $300 Million because they were recouping from physicians. Yet – they continue to do so.

Many medical billers  seem to think that it’s the doctors’ claims that are being sent to the insurance carrier or the hospitals’ claims that they are submitting. It isn’t. It is NEVER the doctor’s claims or the hospital’s claims that are sent to the carrier. Never! It doesn’t matter that the doctor or hospital has an agreement with the carrier or not. It is always the patient’s claim when you are dealing with ERISA.

I know that many still don’t get it – and you’re not alone. I think, after 30 years in this business, that 97% of people in medical offices do not get it and most won’t. Don’t feel alone.

Look at it this way. Let’s take the case you mentioned. Doctor Feelsbetter sends in a claim to BCBS and accepts assignment because he’s a participating doctor. (in 31 states, BCBS would still have to pay the doctor even if he was not par with them – which will surprise most people). Let’s say that BCBS sent the check to the patient this time. Let’s say the patient gets the check and deposits it and then takes cash to the doctor’s office and pays the doctor’s bill. (yes – this sometimes happens – reminiscent of the 70s and 80s of the last century).

Now – two months later, BCBS comes to the doctor and says “we shouldn’t have paid that claim because the patient’s policy lapsed prior to the service and we want that money paid to you by the patient”. Most of the people reading this would say “heck no” simply because they see it as the patient’s money. They would be right.

What many medical billers don’t realize is that there is NO DIFFERENCE between that scenario and the one where the carrier sent the PATIENT’S money to the doctor for the PATIENT’S claim. The US Supreme Court sees it the same way in how they ruled on January 8, 2002 in Great West Life v Knudson.

Yet – people in doctor’s offices think “they sent me the check so I have to give them the money back”, simply because the insurance carriers want them to think that.

It doesn’t matter why the carrier wants the money back. They need to get it from the patient – unless the doctor’s office wants to give it to them and get screwed because they won’t be able to collect it from the patient.

If you have doubts – find an attorney that truly knows ERISA (95% of attorneys do NOT) and ask them to look into the cases mentioned above.

This is why I wrote the book on ERISA at:


Note from the Editor: If you are a medical biller you are handling ERISA claims EVERY day and may not realize it. ERISA Healthcare plans include any group sponsored health plan with the exceptions of churches and government / state plans. PMRNC also has an area to learn more about ERISA and how to appeal claims when ERISA is in play.

Join PMRNC Today!
ERISA? What’s ERISA and What Does it Have to do with Medical Billing?