At Walker Medical Law, we represent health care providers, physicians, social workers, acupuncturists, etc., when their billing has been audited by a health insurance company. We recently completed such a matter, and the journey to the conclusion is an example of how these matters can often be resolved. This matter started in the summer of 2024 when the insurance company sent a letter stating that the audit of the billing was concluded, and that it was decided that our client should send a check in the sum of about $350,000 to settle the matter. We contacted the insurance company and obtained the details of the audit. With those details, our billing specialist, in effect, performed an audit of the audit. That review determined that while the client may have billed the incorrect CPT code on some entries, the company had not given any credit at all for the patient visit. Our position was that the client should have only been asked to reimburse the difference between one CPT code and another. It was, in our view, simply irrational to say that the entire patient encounter should have gone unreimbursed.
Additionally, we located other documents in the client’s office that had not been supplied to the insurance company, and those documents were very helpful in allowing us to argue that the service was given and that the billing, arguably, was correct for some of the items in question. We do this type of investigation on almost all of these cases, as we are often able to prove our point with these other documents. Some of the items that we supply are the actual EKG readings, x-ray reports, EMG readings, patient sign-in sheets, which often show the time the patient checked into the office, signed informed consent documents, emails to and/or from the patient in a patient portal, etc. No one size fits all, but the point is that often, these other documents can bolster our client’s case and thereby reduce the reimbursement claim by the insurance company.
In this recent case, we negotiated a settlement in the sum of $60,000 to be paid monthly, over a year, without any interest. In addition, we supplied training to the client regarding billing so that this type of issue does not arise again.
These types of disputes require careful investigation, and often the claim can be substantially reduced and settled at a figure which is much better than the initial demand from the insurance company.
