What to do when you receive an audit letter from an insurance company

Whether you are a physician or another type of health care provider, you are in a business relationship with health insurance companies that cover your patients. This proves to be true for those who are in their network and those that are an outofnetwork provider.  Although you welcome the checks that the companies send to you, the last thing you want to read is an audit letter, stating that there has been an audit of your billing over the last three years and, unfortunately, the company has decided that you have been overbilling them and that you have to reimburse them an enormous amount of money.  I have seen these types of letters demanding payments of anywhere between $45,000 to $600,000.  

I have noticed that there is a strong probability that the physicians believe the insurance companies must be correct with their calculations.  After all, their only business is all about billing and therefore, they know exactly what the rules are. In other words, physicians feel as if there is no way to fight the issue, making them forced to pay the suggested amount.

However, in my experience, the idea that the people from the insurance company know what they are talking about on this issue is often erroneous. I have many times looked carefully at the details and found that the people at the insurance company actually have a completely wrong way of looking at these matters. For example, companies often state that the wrong billing codes were used and that therefore the company was overbilled. However, many times the proper code is not at all a black or white issue and therefore, there often can be a very cogent argument made that the code utilized was in fact correct.  

Another example is when the company states that the wrong person did the billing and therefore all of the money paid over several years must be repaid.  However, again, the company is not always correct in its assumptions and therefore, one can many times successfully fight the claim.

How do you protect yourself when this type of letter shows up on your desk? In my experience, you should not automatically agree that the insurance company must be correct. You should get some experienced assistance to help you. If it is a coding issue, you probably need a certified coding expert to review the data. This expert can almost always prove that the insurance company’s calculations are clearly wrong. Also, you have to understand the difference between being a contract provider with the company and an out-of-network provider. If you have a contract, you probably have agreed to go to arbitration on any dispute and that can be a problem because one of the terms of arbitration might well be that the loser has to pay the winner’s legal fees. This can potentially be a very big problem because the claimed legal fees might be more than the amount of the claimed overbilling.

If you are an out-of-network provider, the company will have to sue you in court for breach of contract. This is an expensive and time-consuming situation, which can lend itself to a settlement that is far less than the claimed amount

I have been involved with cases where the people at the company actually did not have any idea of the fundamental issues in the case. They might have been new to the company or simply were ignorant of the law or the facts, but in any case when they were faced with opposition they simply backed down from the positions they originally took. This sometimes permitted me to settle the case for pennies on the dollar or, as happened in a very recent case, the company realized they were completely wrong and a $135,000 claim went to zero.  

The lesson to be learned in this type of situation is that you should not assume the insurance company is correct in its claims. The company may be wrong about the facts or the law, or about both. You can fight back. There can be honest disagreements on what the billing should have been and there is always room to negotiate the claims. Also, you should obtain experienced assistance to put forth your point of view. Many times the matter can be settled for a very small payment and sometimes the company will agree that they were incorrect and you will not have to pay anything. With proper representation, you can decide exactly what the facts are and how you should go about putting an end to the matter on terms that are as favorable to you as possible.

When a medical professional is accused of misconduct, it is essential that they retain strong legal representation. If you require a medical law attorney for your legal matters, call Paul E. Walker, an experienced New York City OPMC & OPD Lawyer. Please contact the Walker Medical Law firm to set up a free initial consultation.