Insurance adjustors and third parties use a system of auditing claims that were already paid to the provider in order to prevent fraud and attempt to recoup money that may have been overpaid to healthcare providers. Also known as post-payment review, these retroactive reviews can have a substantial impact on healthcare providers if an adverse determination is made during an insurance audit on claims already paid. If you are subject to an adverse determination, it is critical that you secure the services of an experienced healthcare attorney to handle your claims or else risk paying back significant sums to insurance companies and other creditors.

What Triggers an Adverse Determination?

Occasionally, insurers or disgruntled employees will identify billing codes or patterns that are deemed suspicious by a healthcare provider and trigger an audit. When this occurs, the payor will request medical records associated with the suspicious billing and have a consultant review them. If the consultant determines that an overpayment has been made, an adverse determination can be created with demands for the return of those funds.

Defenses to an Adverse Determination

If an adverse determination is made by an insurance company and the company demands repayment on the audited claim, it is important to know that you have legal options. Two of the most common defenses to adverse determinations are challenges to the merits of the adverse determination and defenses available under the Employee Retirement Income Security Act (ERISA). Challenging the merits of the determination means securing your own consultant services to review their consultant’s review and arguing that the adverse determination was made in error. This can be done by proving that the medical procedures were necessary and fit the standard of care for the situation. ERISA challenges come from determinations that the insurers or other third parties violated the claims procedures and processes mandated under the Act. If it is determined that an ERISA violation took place, an insurer can be barred from recovering overpayments in an adverse determination.

How a Healthcare Attorney can Help

A healthcare attorney is very important to the success of a defense against adverse determinations in insurance audits. A healthcare attorney can help you prepare record submissions for review, secure consultant services, challenge adverse determinations, negotiate with insurers, and prepare the best possible arguments in your defense if the issue goes to court. A healthcare attorney can also preserve your contractual rights and conduct legal appeals to adverse determination challenges. An experienced healthcare attorney also has a comprehensive understanding of ERISA and may be able to nullify claims of adverse determination under this federal Act.

Talk to a Lawyer Today

Attempting to handle adverse determination claims on your own without a healthcare attorney can place you at substantial legal and financial risk. To learn more about how a healthcare attorney can help with your adverse determination claims, call or contact The Martin Law Firm at 215-687-4053.