Provided by: Jennifer Kirschenbaum, Esq.
January 30, 2020
Question:
Jennifer,
HealthFirst is auditing me for charges my biller submitted. I’m saying it that way because she added modifiers indicating I did bilateral but the code itself applies for two sides. I fired her already but now HealthFirst wants the money back.
Any advice?
Thank you,
Dr. W
Answer:
Yes, I have a lot of advice. I started my career with insurance carrier disputes and I’m well into my second decade of resolving/fighting same. Offense is the best defense. Defense alone will not result in a substantial decrease unless there are errors in the findings - unlawful time frame of claims reviewed, improper sample size (tough to win on), argument the money you collected was not profit but used for overhead and taxes. We will need support for the services billed to really cut down or have any chance of eliminating an overpayment as specific as you relay. Here, we have 1 code identified as a billing error (which by your admission seems to have been billed in error). It is unlikely I could exculpate you entirely from the demand.
But, even though in this scenario you may not have a great offense, with defense we can likely mitigate and better position the resolution. Instead of facing potential set off (which you’re likely being threatened with), meaning the overpayment amount is taken from future claims, there is a good chance that with the assistance of counsel we can elevate resolution and negotiate some decrease and perhaps more favorable payment terms.
Importantly, you should not settle without an agreement and release. A release will prohibit the carrier from going back again to look at the same claims for the same or another issue.
If you receive an overpayment demand, it is important for to send over (email is best - jennifer@kirschenbaumesq.com) immediately so you do not miss deadlines.
Jennifer,
HealthFirst is auditing me for charges my biller submitted. I’m saying it that way because she added modifiers indicating I did bilateral but the code itself applies for two sides. I fired her already but now HealthFirst wants the money back.
Any advice?
Thank you,
Dr. W
Answer:
Yes, I have a lot of advice. I started my career with insurance carrier disputes and I’m well into my second decade of resolving/fighting same. Offense is the best defense. Defense alone will not result in a substantial decrease unless there are errors in the findings - unlawful time frame of claims reviewed, improper sample size (tough to win on), argument the money you collected was not profit but used for overhead and taxes. We will need support for the services billed to really cut down or have any chance of eliminating an overpayment as specific as you relay. Here, we have 1 code identified as a billing error (which by your admission seems to have been billed in error). It is unlikely I could exculpate you entirely from the demand.
But, even though in this scenario you may not have a great offense, with defense we can likely mitigate and better position the resolution. Instead of facing potential set off (which you’re likely being threatened with), meaning the overpayment amount is taken from future claims, there is a good chance that with the assistance of counsel we can elevate resolution and negotiate some decrease and perhaps more favorable payment terms.
Importantly, you should not settle without an agreement and release. A release will prohibit the carrier from going back again to look at the same claims for the same or another issue.
If you receive an overpayment demand, it is important for to send over (email is best - jennifer@kirschenbaumesq.com) immediately so you do not miss deadlines.
