Medical Providers: Beware of “Audit” Requests
There is a growing practice by health insurers to pursue medical providers for a refund of monies paid on past claims. The insurers typically start their alleged “overpayment” efforts with audits or ”post payment reviews” of the medical providers’ prior billing on previously closed and paid claims. The medical providers have more defenses available to them than they realize, and they should employ specially qualified counsel to either resist such audit requests or have qualified counsel manage the process.
In the vast majority of situations, the health insurers have no entitlement to a refund whatsoever. For example, if the medical provider is out of network, there is no contractual or other legal obligation to undergo the audit. However, the request by the insurer can indeed provide the medical provider with an opportunity to actually investigate the insurer, instead of having the insurer investigate the medical provider. If the insurer is simply attempting to use the process to intimidate the medical provider, a well-informed and proper response by qualified legal counsel can set things back on track between the provider and the insurer. Even if there are real issues of concern, there are ways to use the tools provided by ERISA (employee benefits law and regulations) to uncover the issues and resolve the problems.
Medical providers should know that they have much more leverage in this context than they realize. With the help of experienced health insurance lawyers to identify the issues and their defenses, the medical providers can maximize their chances of success.
Quadrino Schwartz is also on the cutting edge in this area of health insurance law and has a track record of success in defending medical providers facing retrospective reviews / audits.