Payor relationships, disputes and investigations

Overview

Payor relationships

Our attorneys counsel providers and facilities on payor relationships and billing disputes before they advance to the level of an audit or investigation or even termination of an in-network relationship. Whether this involves contract review and analysis, review of compliance activities, policies and procedures or engaging with consultants or other experts to assist in creating or updating compliance programs, our attorneys work with a wide range of providers and facilities to enhance and improve their relationships with payors. The goal of a good relationship with a payor is one that allows a provider or facility to maximize its reimbursements.

Medicare/Medicaid overpayment audits and appeals

Our services include providing representation to providers and facilitates in all manner of audit and appeals from federally funded health care programs, including responses to medical records requests, notices of post-payment suspensions and pre-payment reviews, overpayment demand appeals and education audits (e.g., Targeted Probe and Educate, SMRC). We also coordinate with independent third-party consultants, when necessary, to bolster a provider’s arguments on appeal directly related to reimbursement issues and statistical extrapolation. We work with a wide range of consultants and facilitate introductions to consultants if appropriate. We have successfully terminated CMS post-payment suspensions and pre-payment reviews on behalf of our clients.

Medicare enrollment/billing privileges appeals

CMS is increasingly more willing to terminate billing privileges and revoke enrollment for providers and facilities. Additionally, with recent rule making CMS can now bar re-enrollment for up to 10 or 20 years depending on the reason for the revocation. It is imperative that providers and facilities mount a detailed and thorough defense at the first level of appeal, the Request for Reconsideration. Our health care attorneys have experience in representing and advising providers with appeals to enrollment revocations and suspensions.

Commercial payor reimbursement disputes, overpayment audits and appeals

We advise clients in all types of disputes with commercial payors. In particular, we provide advice regarding responses to medical records requests and appeals of overpayment demands. We have successfully negotiated settlements for our clients on these overpayments, in some cases resulting in substantial reductions in the overpayment demands. We engage third-party consultants as necessary to reinforce reimbursement of claims for our providers.

Internal investigations, voluntary repayments and self-disclosure

We counsel clients in conducting internal investigations, including structuring the scope and scale of required internal investigations after compliance reviews have determined a potential overpayment pursuant to the 60-day rule. We advise clients on voluntary repayments and self-disclosure through the MACs, OIG, CMS or other entity as required. These investigations can be time consuming, complex and expensive. Our attorneys will work with the provider to make the process of managing the investigation and any required third-party consultants is as efficient as possible.

Government investigations

Our attorneys are experienced in responding to Civil Investigative Demands and subpoenas from the government arising under the anti-kickback laws, the Stark Law, false claims and other state and federal fraud statutes. We can assist with both civil and criminal matters related to health care issues.

Education opportunities

Our attorneys regularly present on these topics to national, regional and local health care associations and frequently write articles, alerts and blogs on payor related topics.