Frier Levitt successfully reversed a $3.66 million overpayment demand from a large commercial payor against a North Carolina medical practice. Cigna’s Corporate Audit Department Special Investigations Unit (SIU) alleged a recoupment liability based on billing violations consisting of insufficient documentation to support billed services, incorrect coding, pass-through billing and unbundled/non-reimbursable services which they assumed were indications of fraud, waste, and abuse.
The allegations were not only unfounded but based on flawed interpretations, misguided assumptions, and a general lack of understanding of patient self-directed home infusions of medications via elastomeric pumps. Frier Levitt worked closely with the practice and a certified professional coder to root out clinical, legal, and coding deficiencies in the audit findings. We helped guide the practice through the complex appeals process, which included gathering additional key evidence to show that in most cases, the violations were not supported due to Cigna’s lack of a binding policy.
Providers facing payor audits need to take them seriously and engage experienced counsel immediately. The initial request from a payor for patient documentation can sometimes appear to be a small random sample, however, when there are multiple dates of services involved, payors routinely use that sample to extrapolate to multiple years. As such, the initial request often fails to alert the Practice of what the massive financial and reputational implications can be. Medical practices believe if they provide the appropriate documentation, the audit will run its course and resolve. Unfortunately, that is rarely the outcome.
To make matters worse, practices often accept a payor’s audit findings at face value without challenging them. This case—where Cigna ultimately abandoned a $3.66 million demand—is a striking reminder of why it’s critical to scrutinize every audit determination, regardless of how forceful or authoritative the demand letter may appear.
This case highlights the benefits of working with a healthcare firm that is not only knowledgeable of the law, but also key underlying clinical issues. Here, Frier Levitt’s attorneys asserted an effective appeal and defense against unjustified allegations by leveraging the in-depth clinical knowledge and combining it with the understanding of payor policies and the appeals process of Guillermo Beades, Esq.
How Frier Levitt Can Help
If your practice is the subject of a payor audit or has received findings with an overpayment demand, Frier Levitt can help you. If you have any questions or need help fighting an audit, contact us to speak to an attorney.
