Summary Plan Description: What In & Out-of-Network Providers Should Know

Event Information
Product Format
Prerecorded Event
Conference Date
Wed, Sep 19, 2018
60 minutes
Product Description

How to Read, Analyze & Interpret a Summary Plan Description to Avoid Costly Litigation

As an employer sponsoring ERISA-covered health and welfare plans, you are legally obligated to communicate the terms of the plan to participants in a summary plan description (SPD). But many plans operate under poorly worded SPDs and leave their sponsors open to liability. You should know how to create a clear and comprehensive SPD, so that you can avoid expensive litigation in the future.

In this audio conference, expert speaker Thomas Force will help you understand what a summary plan description is, what information ERISA requires to be included in the document, and the importance of the information to providers – particularly out of network (OON) providers. You will also learn how to understand the language and terminology of the summary plan description, how to ascertain the important information to determine the amounts allowable, what your appeal rights are, and what procedures are medically necessary.

After attending this session, you’ll be able to read, analyze, interpret, and summarize a summary plan description. You’ll also be able to correctly determine the allowable amounts and medically necessary procedures. Plus, you’ll know your appeal rights – and how to maximize your payment of claims.

Session Highlights

Here’s a taste of what this session will cover:

  • Importance of summary plan description (SPD) for OON providers
  • Definition of medical necessity
  • Appeal rights and procedures
  • External appeals and independent review of claims
  • How eligible expenses and maximum allowable amounts are defined
  • Importance of requesting plan documents

Session Agenda

  • What is a plan document?
  • What is an SPD and an insurance certificate?
  • What is a schedule of benefits?
  • What needs to be in an SPD by law?
  • SPD provisions and sections
    • Glossary/Definition section
    • Deductibles, coinsurance, maximum OOP expenses
    • How to submit a claim
    • Appeal procedure
    • Medically necessary v. investigational or experimental procedures
  • Why the SPD is important to OON providers
    • Medical necessity
    • Eligible expenses
    • Maximum allowable charge calculations
    • Appeal rights, procedures and time periods
  • Who interprets the terms of the plan?
  • What should a provider do when they receive low or no payment on a claim
    • Order plan documents
    • Contact insurer “ smart calls”
    • First and second level appeals and possibly an employer appeal

Who Should Attend

  • In and out of network providers
  • Physicians and staff

Ask a question at the Q&A session following the live event and get advice unique to your situation, directly from our expert speaker.

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About Our Speaker

Thomas Force - Compliance Coding Expert

Thomas J. Force, Esq. is a licensed attorney since 1994 in both state and federal courts in New Jersey and New York, with 27 years of experience in the healthcare and insurance industries. He is the president and founder of The Patriot Group, a full-service healthcare physician advocacy and revenue recovery company providing billing, appeals, collections and follow-up services for healthcare. Thomas is also the former CEO, general counsel and...   More Info
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