Alert: DOL Ramping Up ERISA Health Plan Audits

This is from Chris Vogel at the International Foundation of Employee Benefit Plans:

If you're a trustee or administrator of a self-funded or fully insured health and welfare plan covered by ERISA, be forewarned: The Department of Labor is ramping up audits of health plans. ...

DOL health plan audits will focus on:

• ACA compliance. Are plans making changes mandated by the Affordable Care Act (ACA)​—and changing their design and plan documents? Are they communicating changes sufficiently (or at all) to participants in the summary of benefits and coverage, summaries of material modifications, etc.? 

• Claims denials. This is a big concern. Dingwall says DOL has the sense that a large number of claims are being denied and few are being appealed. Officials worry that participants aren't being given adequate information about the claims appeal process. They also are concerned that emergency room claims are being denied as "unnecessary." Dingwall gave the example of someone who thinks he's having a heart attack, goes to the ER and finds out he has indigestion. ...

When the agency sends a letter telling your plan it will be conducting an audit, DOL will ask for a long list of documents. Andersen suggests the plan should immediately ask for additional time to assemble the documents. ...