Payor reimbursement is the life blood of a physician practice. And yet, even years after a claim is paid, a payor can initiate an audit and attempt to recoup payment. Some payors, including Medicare, utilize statistical sampling and extrapolation to turn relatively small overpayments into six- and even seven-figure extrapolated demands.
Thankfully, a physician almost always has the right to appeal these findings. Medicare, for example, has a multi-level appeal process that includes contractor review and, if necessary, a hearing before an Administrative Law Judge (ALJ) and ultimately review by a federal court.
We have handled hundreds of Medicare, Medicaid, and private payor audits, with overpayment demands ranging from thousands to millions of dollars. In addition to our team of experienced healthcare attorneys, we also work with experts and consultants so that we can be ready for anything that may arise during the audit or appeal process. In addition to overpayment audits by Medicare and its contractors, we also regularly handle Target Probe & Educate (TPE) audits and pre-payment reviews.
Because these appeal processes have strict deadlines, it is crucial that you retain healthcare counsel as soon as you get notified of an audit or alleged overpayment, so that we can begin work immediately and preserve your rights.
Did you know?
During the first two levels of appeal for Medicare overpayment audits (Redetermination and Reconsideration), Medicare cannot begin recoupment as long as the provider submits timely requests (30 and 60 days respectively). Once a reconsideration decision is issued, however, Medicare can begin recoupment, even while your request for an ALJ hearing is pending.