ELAP was founded in 2003 to assist self funded employers in managing the appeal process within their health and welfare benefit plans. Employers sponsoring self funded plans are often ill-equipped to assess appeals that have complex medical and legal implications. These appeals range from coverage determinations to adjudicating medical necessity or appropriateness of treatment. This service remains the cornerstone of our “Basic” ELAP program. ELAP is named in the plan document as the “Designated Decision Maker” (DDM) and serves the plan sponsor in a co-fiduciary capacity. The basic ELAP approach relies heavily on independent review organizations and a rigorous adherence to the Department of Labor (DOL) claim regulations.
In 2007, ELAP recognized that the appeals and challenges were not coming exclusively from plan members, but also from medical providers. The question shifted from: “Is it covered?” (from a member) to: “I am not satisfied with what you paid me” (from a medical provider). The topic of reimbursement for health care services was distinct from the questions and challenges addressed under the basic ELAP model.
To respond to the economic appeals of medical providers, ELAP developed the “Review and Audit Program.” The ELAP audit program compares charges from designated medical providers against allowable claim limits as defined by the plan. These limits ensure that plan payments to medical providers align with objective and verifiable metrics derived from industry sources. The goal of the audit program is to recognize a medical provider’s actual cost in delivering a service and to allow a fair margin above that cost.
The cornerstones of both programs (basic ELAP and ELAP audit) are effective plan language, solid adherence to the intent and letter of ERISA law, and vigorous legal defense of the plan, the member, and the Third Party Administrator (TPA) if necessary.