Healthcare providers whose reimbursement is denied, reduced or questioned by private and public plans rely on Duane Morris attorneys to enforce their rights to demand appropriate reimbursement for services they render. Managed care disputes often involve challenges to appropriate coding, use of modifiers, medical necessity, site of service and other complex factors involved in payment for healthcare services, making this type of dispute much more nuanced than a contract or collection matter.
Duane Morris represents a wide range of individual and group providers in resolving disputes with commercial and government payors, negotiating settlements with federal and state agencies and developing reimbursement strategies at both the state and federal levels. When contesting payor audits and recoupment efforts, our approach involves challenging a number of key areas, including the:
- statistical validity of audit samples;
- ability of payors to employ extrapolation;
- sufficiency of notices of purported overpayments;
- payor documentation of purported inappropriate coding; and
- the ability of payors to engage in unilateral offsets/take backs.
We assist clients pursuing these issues not only in courts and in arbitration and mediation proceedings, but also in administrative hearings, before the Provider Reimbursement Review Board, in carrier or intermediary fair hearings, and through managed care grievance processes. In the event of more serious government involvement for False Claims Act, Stark Act and anti-kickback statute violations, we vigorously defend our clients and work to negotiate settlements that minimize the risk and cost of fines and criminal liability.
With our extensive experience in reimbursement litigation and alternative dispute resolution, our goal is to help clients avoid reimbursement denials and recoupment attempts in the first place, and ultimately help ensure that our clients obtain appropriate reimbursement for the services provided. Duane Morris works closely with our clients to review billing practices, identify and remedy coding and leveling issues, and analyze and mitigate payor policies and procedures implemented to minimize payment reductions. Under attorney-client privilege, we conduct internal investigations to identify and correct billing inconsistencies and reduce the chance of reimbursement denials.