Provided by:  Jennifer Kirschenbaum, Esq.

 April 14, 2011

The basic premise of being compensated for appropriate services you render no longer is a legitimate presumption. Third party payors have succeeded in turning the universe upside down and placing the provider at the mercy of the claims administrator. I see it every day with our clients. Getting paid for legitimate services you render is no longer the norm, but a concept most providers find themselves fighting for on a daily basis. How are third party payors getting away with this? They are placing administrative and procedural hurdles in your way to ensure that you do not regularly meet their documentation requirements. And, how could you with the tactics employed such as the "switcheroo" - which I identify as a third party payor failing to adequately advise you of the "recent changes" or "updates" in submission requirements, pre-authorization or claims follow-up - take your pick! An example of this is I received a complaint this week about a common third party payor for NY docs changing its pre-authorization requirements, requiring providers to obtain pre-auth from a "subsidiary" and those practitioners who "didn't know" are now being denied across the board. Of course, failing to provide adequate notice for procedures is not a valid reason for a denial, and we regularly work with clients citing similar denial to assist in obtaining payment.

Understandably for many providers the process of accounting for ARs is deplorable; one they do not wish to engage in, and therefore, recoupment is left to the biller or practice administrator with less at stake than you have for reimbursement of services you rendered. Delegating reimbursement entirely is a mistake for a few reasons. 1. The reimbursement we are discussing is due to services you have personally rendered, and no one may substitute medical necessity decisions for your own, as you are the treating physician. 2. As mentioned prior, you have more at stake than an administrator. 3. If there is a problem with your documentation or coding, regardless of who is responsible for handling those matters at the practice, if you are the treating provider, at the end of the day you are responsible for your documentation.

In this time of reimbursement crisis, it is imperative that you take an active interest in your documentation and billing. Failing to do so is a critical mistake, one that may come back to bite you even if your claims were paid in the initial instance. The process I am referencing is the ever-more popular recoupment demand. This tactic employed across the board by payors is the second bite at the apple payors have under New York law, where they are authorized to look at your claims and payments post-payment, to review whether medically necessary and substantiated care was provided. Most practitioners who find themselves on "audit" do so because they have set off some kind of red flag with their billing processes. Others may just be unlucky and have been selected by random selection. Regardless, the retrospective review process should be taken seriously and legal counsel should be retained at once to assist. Failing to speak with an attorney as soon as a record request is received may result in increased liability and monetary exposure. Recent experiences we have had representing practitioners dealing with recoupment demands have been largely positive. We have effectively mitigated exposure and negotiated with carriers to reach reasonable settlements.

Bottom line, if you have rendered legitimate services, you should be compensated. And, if you are experiencing push-back from insurers on the front or back end, if you believe your documentation substantiates your services rendered, or you aren't sure, do not simply roll over and forget about compensation. In many instances we are seeing those providers who put a fight rewarded for their efforts!


For additional information on this topic, contact Jennifer Kirschenbaum at (516)-747-6700 ext. 302 or at


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