Does your benefit appeal process feel like it’s on cruise control? It might be time for a tune up. In light of an increase in participant litigation and heightened DOL enforcement efforts, it is imperative that plans ensure their procedures and policies for handling benefit appeals are meeting applicable law and plan documents.

Does Your Benefit Appeal Process Need a Tune-Up?
“Each and every claim should be treated like it might be in front of a judge,” said Daniel Brice, Esq., Partner at Blitman & King LLP, as he broke down the art of claims and appeals in a recent webcast, Anatomy of a Benefit Appeal—A Discussion and Primer on the Best Practices for Handling Benefit Appeals. The webcast walks through each step of the appeal process, including a litigation challenge of benefit denials. If you’re looking to gain a better understanding of how to develop a structure for handling benefit appeals (that will put your plan in the best possible position in the event of a litigation or audit), you’ll want to listen to the full webcast on demand.Washington Legislative Update

Mr. Brice focused on four key takeaways when dealing with health and pension plan claims and appeals to legally protect yourself in the process:

  1. Check and Check: Develop an internal checklist when handling claims and appeals. Use a template to fill out different steps needed but don’t rely on it so much that you miss out on important details.
  2. Speak the Same Language: Keep everything in writing and make sure plan language and notification letters are compliant with the law.
  3. It’s a Match: Apply uniform procedures consistent with DOL mandates in addressing appeals to provide a consistent and reliable process.
  4. Stay in the Know: Keep up to date on developments in the law. The new administration is bringing many unknowns to a number of federal government rules, so make sure you’re aware of what’s changing in requirements for claims and appeals.

A bigger-picture look at your claims and appeals process is highly encouraged by Mr. Brice. Ask yourself if there are any loose screws that need tightening when you’re going through each step.

[Related: Health Care Management Conference, May 1-3, 2017, New Orleans, Louisiana]

“Be more careful” is the phrase Mr. Brice uses—“I know you’ve got 35 things to do on a Wednesday afternoon and you want to get the appeal off your desk, but I can’t stress enough to take the time to make sure each bullet is checked off,” he said.

All plans should be prepared at all times as if they’re going to get audited the next day. This preparation will especially help if you are challenged in court or if the DOL knocks on your door and you have to explain your rationales.

For a detailed look at how to start examining your claims and appeals process, tune into the webcast.

Anne Killian
Communications Associate at the International Foundation


Anne Patterson

Communications Associate at the International Foundation

Favorite Foundation service/product: The innovative member survey efforts and results from the research team.

Benefits-related topics that interest her most: Health care, nontraditional wellness initiatives, employee benefit communication.

Personal Insight: It’s all about balance with Anne. She loves to run and enjoys a good culinary adventure. She’ll jump at the chance to travel or to spend fun times with family and friends, but she’ll also take time to catch her breath with an occasional Netflix binge or diving into a classic novel.

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