A substantial part of the practice here at Walker Medical Law consists of representing physicians, therapists, acupuncturists, and other health care professionals in cases where their billing for treatment is questioned by a health insurance company. This starts out with a letter stating that the company is going to audit your records, and they ask for a sampling of your records. After several months go by, you receive a letter stating that the company has determined that you have incorrectly billed in numerous ways and that the audit has yielded a certain percentage error rate. The letter goes on to say that the error rate has been used to “extrapolate,” and that means they apply the percentage error against all of your billing for the last, say, four or five years. The letter ends by saying this problem can be easily resolved by you sending a re-payment check to the company in the amount, usually, of hundreds of thousands of dollars. It is at this time that practitioners call us.
At the firm, we have on board people with years of experience in the medical billing area, and we put that expertise to work for our clients. The first thing we do is obtain the audit results and look at the methodology used by the company and its auditors. We then review all of the records you provided to the auditors, and then we audit the audit. In other words, we look to see where the auditors are simply wrong or where there can be an honest difference of opinion regarding which codes were used. Also, we almost always find that our client has other documentation that would be helpful in defending against the claim, like, patient check-in sheets that were not put in the medical records, or correspondence from other providers that were not placed in the record but will be helpful in supporting the billing that was done.
We also provide instructional sessions with the client to ensure that these billing issues do not arise in the future. Those concepts are then put down into a Corrective Action Plan, which is then submitted to the insurance company.
We then have a meeting with the company, we present our case, and the negotiations begin. On some occasions, our client ends up paying nothing, as the number is too small or because we can actually support all of the billing. However, most of the time, a monetary resolution is reached, and the issue is exactly what the final figure is going to be. This is where experience, coupled with expertise, comes into play. There is a give and take because the client wants to keep the insurance company’s insureds as his/her patients, and the insurance company does not want the patients to suddenly all have to find new doctors to take care of them. The final repayment settlement figure is based on a multitude of factors, and each case is sui generis. However, we do know the pressure points that we can apply, and we also understand that there is only so hard that you can push because neither side wants to ruin the relationship.
So, if you receive such a letter, please do not try to resolve it yourself. These cases are nuanced, and you will want to find some solid advice that will lead you to the best possible outcome in this very unpleasant situation.
