This summer, our firm attended the Healthcare Leaders Association of New Jersey (HLA NJ) Annual Conference. Our firm spoke about how to defend against payor audits and highlighted the frequently used tactic of “pre-payment reviews” that payors have leveraged to interrupt cashflow and yield extrapolated overpayment demands.
During the conference, we also had the pleasure of co-speaking with Empower Healthcare & Compliance Partners (EHCP) in a roundtable discussion addressing the pivotal issue of early intervention by legal and compliance professionals, emphasizing its crucial role in disputes with payors.
The panelists noted common missteps they have observed over the years defending audits and overpayment demands. Drawing an analogy to healthcare, they demonstrated that just as early medical intervention and consults with experts leads to better outcomes, promptly involving legal and compliance experts in payor challenges significantly boosts the chances of a favorable resolution.
Payors frequently employ tactics to underpay, delay payments, or recoup previously paid claims from providers. While there are warning signs indicating an impending audit or area of concern, these signals often go unnoticed by busy practices. The panel stressed the importance of consistently challenging unfavorable payor decisions, noting that allowing payors to engage in unfair practices without resistance only encourages them to repeat and potentially escalate such actions in the future.
One common scenario discussed involved practices receiving audit letters but delaying seeking legal counsel until months later, by which time the audit has escalated to an overpayment demand or worse. The panelists emphasized that no audit should be considered “routine,” as audits target specific areas of practice, codes, or providers based on the payor’s analytics and audits of other practices. For example, in New Jersey, payors are currently scrutinizing highly reimbursable procedure codes such as custom orthotics in podiatry, balloon procedures in otolaryngology, and audiology testing in pediatrics.
To combat these challenges, the panel advocated for a proactive approach, advising providers to take immediate action at the first sign of an audit or underpayment. If a practice is being underpaid or denied legitimate claims, it should hold the payor accountable by filing internal appeals, reaching out to provider representatives, considering legal action, or filing complaints with regulatory bodies.
Furthermore, if a practice is undergoing any type of audit, whether pre-payment or post-payment, it should strongly consider retaining the services of a healthcare attorney and coding expert immediately. This early intervention allows for thorough due diligence and early advocacy, increasing the chances of a favorable outcome and mitigating potential risks.
The panelists underscored that auditors and investigators within the insurance industry often work closely with their compliance, legal, and executive teams when conducting audits or seeking recoupments. Therefore, providers should adopt a similarly collaborative approach, working closely with their own compliance staff, legal counsel, and leadership to present a unified front and mount a robust defense against unfair overpayment demands.
The roundtable discussion at HLA NJ’s 2024 Annual Conference highlighted that a proactive approach and close collaboration with legal and compliance experts can significantly improve the likelihood of favorable resolutions when facing payor disputes and challenges.
How Frier Levitt Can Help
If you are facing payor disputes, audits or adverse actions, don’t wait, contact Frier Levitt to speak with an attorney today. Our legal team possesses a wealth of knowledge and experience securing favorable outcomes for practices undergoing payor challenges.
