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The Medical Practice Guide to ERISA: Employee Retirement Income Security Act

The Medical Practice Guide to ERISA: Employee Retirement Income Security Act

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Don Self and Steve Verno

Book helps medical practices use the secrets within the ERISA regulations to their benefit and an increase in practice profitability.

The Federal law ERISA (Employee Retirement Income Security Act) helps the majority of medical practices make carriers pay on claims that are now being denied, delayed and recouped. A small percentage of practices understand how ERISA works -- yet with this new book, ERISA could possibly become a practice's best friend!

ERISA is complex and most medical practices "Don't know what they don't know when it comes to dealing with ERISA!" Practices are in the dark in understanding how to protect their employer's rights in collecting the monies owed them. All practices have problems with timely filing denials and refund requests, and this book provides simple guidance on how to use ERISA and make it work for the practice's best interest.

Insurance carriers, third-party payers, fiduciaries, and health plans are, quite often, not paying the way they should -- or they are not playing fair with providers. Most providers do not understand the laws regarding payment.

Do you realize that most of the claims that you file are likely to be ERISA claims? Do you know how to stop carriers from recouping on claims unfairly? Do you understand that many parts of the contracts that your providers have signed are invalid?

The authors map out the smart but ingeniously simple tactics that practices can use to force insurance carriers to honor their responsibilities on the policies owned by patients -- and to convince the carriers to adhere to what the policies actually require them to cover.

This book describes an overview of the ERISA law, and provides tips, tools and techniques to leverage ERISA for practice advantage. The authors discuss what claims are covered and what does it mean to be covered? They take a close look at real-world ERISA situations, violations and outcomes.

This focused book educates physicians, practice leaders, hospital staff, billers and managers on how to use ERISA to force insurance carriers to honor their responsibilities on the policies that are owned by patients. You may think you have all your bases covered, but with ERISA's complex rules and regulations, it is easy to overlook key issues. Authors and experienced consultants Don Self and Steve Verno identify the key areas of ERISA that practices need to understand and they are on a quest to ensure that your claims are paid properly, fairly, and equitable. In demand on the National level in both speaking and writing, the authors offer solutions that have been proven successful in other medical practices. Armed with this roadmap, physicians and executive staff can better put their resources to work-- leveraging ERISA to improve practice profitability.

Using this book will allow the reader to not only capture the funds on thousands of dollars that the carriers are now unfairly denying, but will empower the reader to stop the unfair recoupments, illegal timely filing and improper appeal periods that carriers mistakenly quote to physicians and hospital offices.

The authors map out the smart but ingeniously simple tactics that practices can start to use immediately. This book allows the physician, manager, and billing staff to take the power back!

Noteworthy Features

  • Clear Roadmap - Written in layman's terms so practice leaders can immediately begin to implement a strategy of getting claims paid, how to fight denials, halt recoupment
  • Very Practical - Includes real world examples and case studies of how medical practices can use the ERISA rules to work for them. Also practical information on how to use the ERISA website and answers to the most frequently asked questions.
  • Templates to Get You Started - Sample letters (describing exact situations and how they can be handled) will get you started and help you take control of the process!


Table of Contents

  • Healthcare Basics
  • Definitions
  • Laws
  • Employee Benefits Security Administration: Frequently Asked Questions about ERISA
  • Using ERISA
  • Claims Issues
  • Sample Letters -- Timely Filing Denial Response, Refund Demand Layperson Response, Unpaid Claims Letter, Incorrectly Paid Claims Letter, Bundling Denial Letter, Downcoding Letter, Payment to Patient Letter
  • Additional Resources: Helpful Websites, Layperson Documents Authorized Representation, Assignment of Benefit Form


Don Self

Don Self has been a medical reimbursement consultant for more than 26 years and has taught hundreds of seminars to physicians, mid-level providers, office managers, billers and medical office personnel in almost every state of the United States. His website is regularly visited by thousands, and his first book, The Unfiltered Guide to Medical Office Management, is in its fourth printing.


Steve Varno

Steve Verno is a Certified Medical Billing Specialist (CMBS), a Certified Medical Billing Specialist On Line Instructor with the Medical Association of Billers, a Certified Multispecialty Coding Specialist (CMSCS), a Certified Emergency Medicine Coding Specialist (CEMCS) with the Professional Association of Healthcare Coding Specialists, and a Certified Practice Manager-Medical Coding Specialist (CPM-MCS) with the Physician Office Managers Association of America (POMAA). His specialties include Emergency Medicine, Family Practice, Pediatrics, Urgent Care, Internal Medicine, Accounts Receivables Recovery, Appeals, ICD-10-CM, ERISA, Fraud and Abuse, and Compliance.

5.0 out of 5 stars A must have for any Practice Manager

By Amazon Frequent Flyer (California) 

As always Don Self knows what we need to hear, even if we don't want to. This book is comprehensive and delivered in a style known to keep your interest! Thanks again Don. I look forward to your next.

5.0 out of 5 stars Great book!

By Bradley G. Kirk (Lexington, TN United States)

Don't let the price scare you away -- this book is a bargain. Well written and contains tons of useful information.

5.0 out of 5 stars Easy to read and very informative

By djohns57

Good read to learn background information and information necessary to manage these regulations in a medical practice. I would recommend to anyone.

5.0 out of 5 stars Secrets your Insurance Company doesn't want you to know!,

By Charlene 

To all my Healthcare billing friends and health care journalists: This is a must buy! Quite frankly, this is important even if you are a layperson covered under your employer's group health plan! These are the secrets that your insurance company doesn't want you or your doctor's office to know! This book provides the actual legislation that can be used to fight insurance companies, even if you have a contract with the insurance company. Don and Steve have provided actual templates for letters that your office can send to the insurance companies for a variety of different issues. Fight the insurance companies' timely filing denials, recoupments and refund requests. Keep the much needed revenue, that physicians work hard for, in your office!

"Don Self can be a physician practice's best friend. With decades of experience in practice management, Don is an expert at identifying compliance concerns and areas where physicians have failed to hold private payers accountable for their financial obligations. Not one to mince words, Don's perspective is never hard to discern. He is unapologetic in his beliefs and does not hesitate to stand up for the rights of physicians he represents. Don's latest book, authored with Steve Verno and examining the basics of ERISA, is sure to turn a few heads.”

Robert W. Liles, JD, M., MBA
Managing Partner
Liles Parker
Attorneys & Counselors at Law
Washington, DC

"Finally!" A long awaited and much anticipated book about ERISA by two well-respected leaders in the healthcare industry. This book will provide the secrets in getting claims paid, how to fight denials, and halt recoupments using the features right there within the ERISA regulations. This is what insurance companies do not want you to know!"

Charlene Endre-Burgett, MS, CMA (AAMA), CPD, CMSCS
Administrator, North Scottsdale Family Medicine