The Martin Law Firm is an experienced healthcare law firm located in Blue Bell, Pennsylvania. Attorney Jason B. Martin is a skilled and knowledgeable healthcare attorney with a practice focusing on Medicare audits, Medicare appeals, insurance audits, ERISA, Stark and Anti-Kickback laws, and other general business matters for healthcare providers. Our clients include MDs, DOs, DPMs, PTs, DCs, ASCs, and hospitals and health systems. The Martin Law Firm, although based in Pennsylvania, helps provider clients all across the nation, utilizing its vast network of attorneys and other healthcare professionals for providing effective and efficient representation.
In their quest to prevent fraud and recoupment of monies allegedly overpaid to healthcare providers, insurance and other third party payers often utilize a system for auditing claims that were already paid to the provider. These retroactive reviews, often referred to as post-payment reviews, can be quite challenging for a healthcare provider because an adverse determination can lead to significant monetary demands.
What Triggers an Insurance Audit?
Insurance and third party payers usually identify coding or billing patterns that lead to speculation that the provider is doing something wrong. Sometimes, a disgruntled employee or patient will notify the payor of imp improper billing and/or coding. When this occurs, the payor will send the provider a written request for medical records and the payor will have a consultant review the documentation. The consultant’s conclusion can lead to a determination that payments for prior claims were in error. This leads to a demand or a return of the overpayment.
What Happens if I do Not Return the Overpayment?
The insurance or third party payor often makes the written demand for payment and gives the provider a certain amount of time to return the alleged overpayment. The provider can either pay, work out a payment plan with cooperation from the payor, appeal the decision, or do nothing – at which point the payor will recoup or offset the amounts owed against current claims submissions.
What do I do if an Insurance Company or Third Party Payor Requests Records?
It is important to contact an experienced healthcare attorney as soon as possible. A healthcare attorney can advise you of your rights with regard to submitting the records. In addition, a skilled healthcare attorney, often with the assistance of a coding professional, can review the records before they are submitted and may help you create narrative summary reports to be included with the records. The summary reports are created to help further explain the care provided to the patient and the summary reports can help the consultant understand the treatment history. A healthcare attorney can also help you take corrective action if it is determined that you have been doing something wrong. Sometimes, the payor takes months to make a determination, and it is advantageous for a provider to correct any errors or deficiencies in the meantime.
What Can I do if the Payor Makes an Adverse Determination?
If an adverse determination is made and the payor makes a demand for payment, the provider, if he or she hasn’t done so already, should immediately seek the assistance of an experienced healthcare attorney. The attorney can defend the provider and challenge the determination through the applicable appeals process. There are two basic defense strategies: challenging the merits of the determination, or ERISA (Employee Retirement Income Security Act). Insurance and third party payers often violate the claims procedures process provided under ERISA, which may bar them from recovery of overpayments. In addition, insurance and third party payers may not have a legal basis for recovery of overpayments under ERISA.
Contact an Experienced Healthcare Attorney in PA
The Martin Law Firm can help you prepare for records submissions, challenge the basis for an overpayment determination, preserve your contractual and legal appeal rights, and use ERISA, when appropriate, to challenge the insurer’s ability to recoup. Recent federal court ERISA decisions have given healthcare providers an enormously powerful ability to challenge insurance post payment reviews and recoupment efforts.
The Martin Law Firm is a Pennsylvania health law firm that assists providers with insurance and third party payor audits (post-payment reviews) and recoupment. We counsel all healthcare providers on how to avoid audits through effective compliance programs, and, if necessary, we provide aggressive defense for the provider facing a post-payment review.