Who Regulates the Third-Party Administrator of ERISA Plans?

 

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Q.  Who regulates the third-party administrator of employer-sponsored, self-funded health plans? Can I bypass the third-party administrator and seek payment from the employer when reimbursement for a claim is stalled unreasonably? What confuses me is that these plans "pend" claims for information they can obtain easily without delay; after all, the insured patient works for the company sponsoring the plan. Can the Texas Department of Insurance (TDI) help me with these claims?

 

 

A.  The prompt payment laws and clean claim rules enforced by TDI do not apply to valid employer-sponsored, self-funded plans. These plans are subject to the federal Employee Retirement Income Security Act of 1974 (ERISA) and U.S. Department of Labor regulations. Frequently, the plans contract with a third-party administrator to administer the plan, process health care claims, and make payment to physicians. A third-party administrator of an ERISA plan is exempt from TDI regulation.

You may seek payment from the employer who sponsors an ERISA plan, but ERISA regulations do not mandate a time frame for payment. Additionally, the employer may choose not to deal directly with a physician by referring your inquiry back to the third-party administrator.

Physicians' rights under ERISA are very limited. For more information, read the Department of Labor's FAQs or contact the agency at one of the locations below.

National Office:
U.S. Department of Labor
Division of Technical Assistance and Inquiries
200 Constitution Ave. NW, Room N-5619
Washington, DC 20210
Phone: (202) 693-8632

Regional Office:
U.S. Department of Labor
Dallas Regional Office
525 Griffin St.
Dallas, TX 75202-5025
Phone: (972) 850-4500

 


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