Many payers’ Special Investigation Units (“SIU”) frequently audit healthcare providers on parallel tracks, meaning that they will seek to recoup on behalf of the commercial side as well as their Medicaid or Medicare Advantage arm as well. When this happens, providers must sometimes defend against two (2) completely different sets of auditing rules, as the Medicaid plan will sometimes have different requirements than the commercial plan.
When dealing with an overpayment demand from a carrier that is seeking to recoup from both a commercial plan and a Medicaid managed care plan as part of one joint demand, healthcare counsel is crucial to cut through the red tape and determine the validity of the demand.
Strategic Legal Defense Leads to Full Commercial Audit Reversal
In a recent case, Frier Levitt successfully reversed a nearly $170,000 overpayment demand issued by a major New Jersey commercial payer. The payer conducted an audit and alleged insufficient documentation for custom orthotics and related podiatric services, raising concerns about conservative treatments, heel cup depth, and compliance with the payer’s internal policies.
Our team of skilled healthcare attorneys collaborated closely with certified coders and utilized our client’s clinical expertise to thoroughly review the audit findings, payer policies, and medical documentation.
Through this comprehensive analysis, we identified key inaccuracies in the payer’s alleged findings and prepared a robust appeal that rebutted the alleged deficiencies.
In instances where the documentation appeared deficient, we proactively addressed the allegations by providing attestations and additional supporting evidence to rectify perceived gaps. In addition, we challenged the payer’s improper expansion of the audit scope, asserting that records outside the specified review period had been requested, further undermining the integrity of the audit.
By presenting expert analysis and pointing out overlooked elements, we demonstrated that the documentation fully complied with all relevant payer policies and standards. This strategic defense led to a 100% reversal of the alleged overpayment demand.
Major Medicaid Reduction Follows Commercial Audit Victory
In a separate audit targeting the same provider, the payer’s Medicaid division alleged a nearly $75,000 extrapolated overpayment related to services rendered by non-credentialed providers.
In this matter, we successfully challenged the audit’s underlying extrapolation, demonstrating it was methodologically unsound. As a result, we were able to secure a nearly 45% reduction in the alleged Medicaid overpayment.
Through these efforts, we not only fully reversed the commercial audit but also substantially reduced the Medicaid audit, resulting in a highly favorable outcome for our client across both audits.
Audit Findings Should Be Challenged
Many healthcare providers mistakenly assume that once a payer issues an audit finding, the matter is resolved. However, payer audit findings are not final determinations. Payers may overlook critical documentation, misapply coverage standards, misinterpret policies, or rely on flawed sampling methodologies. With skilled legal representation, these findings can be effectively challenged and often reversed.
At Frier Levitt, we specialize in identifying errors, presenting well-supported arguments, and leveraging expert analysis to protect our clients from unjustified overpayment demands. We scrutinize every audit finding, ensuring that all aspects are thoroughly examined, and errors are addressed.
Protect Your Practice with Frier Levitt
If your practice is facing an audit or overpayment demand, swift action is essential. The stakes are high, and timely intervention is crucial to protect your financial interests and professional reputation.
Frier Levitt’s Audit Defense Team has extensive experience navigating complex payer audits and safeguarding practices from further scrutiny. We tailor our defense strategy to each case to achieve the best possible outcome for our clients.
Contact Frier Levitt Today
Don’t let unjust audit findings jeopardize your practice’s future. Contact Frier Levitt to learn how we can help you challenge payer audits and protect your practice.
Frier Levitt provides strategic, industry-focused legal counsel tailored to your needs. Contact our team today to learn how we can help you.
