ERISA Recovery Review: What It Is, How It Works, and Which Surgeons Should Use It
ERISA recovery review is a legal evaluation of underpaid or denied medical claims from an ERISA-governed commercial health plan. Instead of accepting the insurer’s payment as final, the review identifies errors, ERISA violations, and missed reimbursement opportunities that may allow surgeons to recover additional payment.
For many surgeons, underpaid or denied claims are written off after routine billing, follow-up, and appeals fail. A common industry benchmark suggests that mid-sized surgical practices lose 4% to 9% of their annual revenue to uncaptured underpayments. That’s approximately $250,000 to more than $1.5 million each year.
If you're dealing with underpaid out-of-network claims involving ERISA-governed health plans, Callagy Recovery can help determine whether additional reimbursement is available and handle the recovery process for you.
What Is ERISA Recovery Review?
ERISA recovery review is a legal reimbursement analysis that examines an underpaid medical claim to determine whether the insurer correctly processed and paid the claim under an ERISA-governed health plan. Specialists review the following documents and claim details:
- Patient’s health plan documents. Review the plan’s coverage terms, reimbursement rules, and payment requirements.
- Explanation of Benefits (EOBs). Analyze the insurer’s payment decision, including the billed amount, allowed amount, payment, and reason for any reduction or denial.
- Payment records. Verify what the insurer paid and identify possible reimbursement errors.
- Previous appeals and correspondence. Review prior disputes, insurer responses, and explanations for the payment decision.
- Claim handling details. Evaluate how the insurer processed the claim and whether proper procedures were followed.
If specialists identify an issue with the insurer’s payment, surgeons may pursue additional reimbursement.
What Types of Underpaid Claims Should Be Reviewed for ERISA Recovery?
- High-value surgical claims where even a small payment reduction can result in significant revenue loss.
- Aged, zero-balance, or written-off claims that were considered uncollectible after standard billing efforts but may still contain additional reimbursement opportunities.
- Out-of-network claims where no negotiated contract rate exists, and insurers determine initial payment using the Qualifying Payment Amount (QPA).
- Claims affected by third-party repricing vendors that may reduce reimbursement below what the ERISA health plan requires.
- Claims with improper downcoding, unbundling, incorrect modifier reductions, or denied assistant surgeon fees that the insurer refused to resolve through routine billing appeals.
- Claims denied or underpaid based on health plan interpretation or incorrect application of plan terms.
- Claims where the insurer’s payment does not match the plan’s reimbursement requirements.
Which Surgeons Benefit Most From ERISA Recovery Review?
- Neurosurgeons. Brain and spine procedures are complex and involve multiple services, making them more likely to be underpaid or incorrectly reimbursed.
- Orthopedic surgeons. Joint replacements, spinal fusions, fracture repairs, and other implant procedures have high-value claims where even a single underpayment can lead to significant lost revenue.
- Out-of-network surgeons. Out-of-network procedures usually receive low initial payment based on the Qualifying Payment Amount (QPA), which is the insurer’s median in-network contracted rate for the same or similar service.
- Reconstructive and plastic surgeons. Medically necessary reconstructive procedures can be denied or paid as if they are not medically necessary, leading to lower reimbursement.
- General and trauma surgeons. Emergency and trauma procedures are often performed without a direct contract with the patient's insurer, increasing the risk of underpaid out-of-network claims.
- Hospital-based surgeons. On-call or facility-based care treats patients they can’t choose, making unexpected out-of-network underpayments more common.
How Does ERISA Recovery Review Work?
Step 1. Confirm the Underpaid Claim Qualifies for ERISA Recovery Review
- Verify the patient’s health insurance is an ERISA-governed health plan. This is typically a private, self-funded employer plan.
- Have the patient sign a valid Assignment of Benefits (AOB) or Designation of Authorized Representative (DAR) form permitting surgeons to pursue reimbursement on the patient's behalf.
- See if the Explanation of Benefits (EOB) is still within the required deadlines for filing an appeal or pursuing additional reimbursement. ERISA appeals are generally due within 180 days of the EOB, while eligible out-of-network claims under the No Surprises Act have a 30-business-day deadline.
Step 2. Review the ERISA Health Plan and Insurer's Payment
- Compare the insurer's payment with the reimbursement rules written in the Summary Plan Description (SPD) and health plan documents. See whether the insurer followed the plan’s payment terms.
- Check how the insurer calculated the payment to determine if the claim was underpaid, downcoded, or reduced using third-party repricing vendors (such as MultiPlan or Zelis) or another payment method not permitted by the health plan.
- Request the insurer's complete claim file, payment methodology, and supporting documents. Review them to determine whether the insurer responded within deadlines, cited the correct health plan provisions, and used qualified medical reviewers when making the payment decision.
Step 3. Choose the Appropriate ERISA Recovery Path
- Administrative ERISA appeal is for underpaid claims involving payment errors, contract misinterpretations, or procedural issues. Prepare and file a formal appeal using the health plan's exact terms, supporting clinical documents, and federal ERISA guidelines to challenge the insurer's payment decision.
- Federal Independent Dispute Resolution (IDR) is for eligible out-of-network underpaid claims covered by the No Surprises Act. Complete the required 30-business-day open negotiation period. If no agreement is reached, submit the dispute to an arbitrator to decide the appropriate reimbursement.
- ERISA Litigation is for high-value underpaid medical claims or repeated patterns of underpayment that can’t be resolved through administrative appeals or arbitration. These cases are handed over to a specialized healthcare attorney to take legal action in court against the insurer.
How Much Can You Recover With ERISA Recovery?
You can recover anywhere from $6,000 to $1.2 million with ERISA recovery. A New York hospital recovered $1.2 million from 250 denied in-network breast reconstruction claims. An anesthesia provider recovered $750,000 after several claims for CRNA services and Propofol were denied. In 2025, Callagy Recovery helped Dr. Rhys Kaan recover $944,124 from multiple out-of-network spinal surgeries. Here are Callagy Recovery's average recoveries by out-of-network specialty through Federal IDR:
Specialty | Average Out-Of-Network Recovery
|
|---|---|
Neurosurgery | $83,120 |
Orthopedic Surgery | $41,580 |
Neurologist | $36,298 |
Plastic Surgery | $31,828 |
Pain Management | $25,568 |
Other Sp | $23,827 |
Intraoperative Neurophysiology | $17,547 |
Hand Surgery | $13,121 |
Emergency Medicine | $10,100 |
General Surgery | $8,278 |
Anesthesiology | $6,410 |
How Far Back Can an ERISA Recovery Review Go?
An ERISA Recovery Review can go as far back as 30 days to 10 years, depending on the type of claim, recovery pathway, and applicable deadlines.
Specialized ERISA recovery reviews evaluate underpaid or zero-balance claims from up to 10 years ago by examining plan documents, payment records, and insurer compliance. These reviews identify issues that extend beyond standard 180-day appeal deadlines. ERISA litigation has shorter time limits, typically ranging from 3 to 6 years depending on state law and the terms of the health plan.
However, for out-of-network claims pursued through Federal IDR under the No Surprises Act, the timeline is much shorter. Surgeons must initiate open negotiations within 30 business days of receiving an initial payment or denial notice. Then, they must file for IDR within 4 business days after the negotiation period ends. If you miss these strict deadlines, the money stays with the insurance company.
What Happens if an Insurer Ignores an ERISA Appeal During the Review Process?
If an insurer ignores an ERISA appeal during the review process, the appeal may be considered “deemed exhausted.” This means the surgeon may move forward without waiting for the insurer’s internal review process to finish. Under Department of Labor rules, the surgeon may then pursue next steps, such as taking legal action under ERISA.
How Long Does the ERISA Recovery Review Process Take?
Administrative ERISA appeal - typically 2 to 4 months from claim review to payment.
Federal IDR - around 3 to 6 months from open negotiation to final arbitration decision.
ERISA litigation - usually 6 months to 2+ years due to complex lawsuits and court proceedings.
How Is ERISA Recovery Different From Routine Billing?
Routine Billing | ERISA Recovery | |
|---|---|---|
Primary Focus | Submits new claims and collects the initial payment. | Reviews underpaid ERISA claims to recover additional reimbursement. |
Documents Reviewed | CPT codes, ICD-10 codes, modifiers, claim forms, and the EOB. | Summary Plan Description (SPD), EOB, payment records, and the insurer’s claim file. |
How Issues Are Resolved | Files standard billing appeals with the insurer. | Uses ERISA appeals, Federal IDR, or ERISA litigation. |
Governing Law | State insurance laws, payer policies, and surgeon contracts. | Federal ERISA law and, when applicable for out-of-network, the No Surprises Act. |
Goal | Receive the correct payment during the normal billing process. | Recover additional reimbursement after routine billing is complete. |
Can Surgeons, RCM Companies, and Billing Teams Conduct Their Own ERISA Recovery Review?
Yes, surgeons, RCM companies, and billing teams can conduct their own ERISA recovery review. However, the process is highly specialized, time-consuming, and extends beyond their day-to-day responsibilities.
An ERISA recovery review requires more than identifying an underpaid or denied claim. It involves analyzing the employer’s Summary Plan Description, reviewing the health plan’s claim and appeal procedures, understanding ERISA violations, researching applicable federal laws and case precedent, and preparing legally supported appeals.
For that reason, most surgeons, RCM companies, and billing teams choose to partner with an ERISA recovery firm or medical revenue recovery expert. This way, they have higher chances of recovering the money owed.
Why Choose Callagy Recovery for Out-of-Network ERISA Recovery?
- We specialize in recovering underpaid out-of-network claims. Without a negotiated contract rate, insurance companies are more likely to underpay these claims. In fact, 60%-70% of ERISA recovery cases involve out-of-network claims.
- You don't have to pay any upfront fees. You only pay a 20% contingency fee on the amount we successfully recover.
- We recover 5 to 15 times more than the insurer’s initial payment. For example, if an insurer initially pays $5,000, we may recover an additional $25,000 to $75,000 on an eligible claim.
- We have 27+ years of experience. Callagy Recovery knows exactly how to challenge insurer underpayment tactics.
- We manage every deadline. We track every Federal IDR deadline and filing requirement so you never miss an opportunity to recover additional reimbursement.
- You're informed every step of the way. Our secure portal lets you track the status of your underpaid claims throughout the Federal IDR process.
- We have a proven track record. Callagy Recovery files around 4,000 cases every month, wins 94% of them, and has recovered more than $1 billion for healthcare providers.
- We focus on high-value surgical claims. These claims often lose the most revenue when insurers underpay, creating some of the greatest opportunities for additional reimbursement.
- We’re backed by Callagy Law. We combine legal knowledge with reimbursement expertise to build stronger cases for every claim we pursue. Callagy Law also handles in-network and out-of-network ERISA recovery litigation.
- We handle the entire recovery process. From reviewing claim eligibility and gathering documentation to preparing appeals and managing disputes, we work on every step.
- We offer a free claim analysis. We’ll review your underpaid out-of-network claims at no cost to determine whether ERISA recovery may be available.
Don’t Leave Underpaid Claims Unrecovered. Start Your ERISA Recovery Review Today!
Many surgeons close underpaid claims after completing the standard billing appeals process. However, these claims may still qualify for additional reimbursement. ERISA recovery review examines these claims to identify potential recovery opportunities. If it qualifies, you can formally challenge insurers through ERISA administrative appeals, Federal IDR, or ERISA litigation.
For underpaid in-network claims, Callagy Law offers ERISA litigation services. But if you have an out-of-network claim, Callagy Recovery can review it to determine if it’s eligible for Federal IDR under the No Surprises Act. We manage the entire process and often recover as much as 5x to 15x the insurer’s initial payment.
So don’t delay! Start your ERISA recovery review today to identify potential recovery opportunities.
