Guidance For Denials, Offsets And Recoupment

Once an audit or initial investigation concludes, the government or a commercial insurance may deny payment for a various number of reasons (including lack of medical necessity, failure to timely file or appeal, improper billing or coding, etc.). Medicare, Medicaid, or a commercial insurance might determine that the healthcare organization was overpaid on a certain number and type of claims.

To recover the alleged overpayment, the government or commercial insurance may seek to offset or recoup such amount through future payments to that organization. The government or commercial insurance may also or alternatively suspend a provider, which is particularly problematic. When this occurs, the ability to bill for certain services and procedures is at stake as well as the sustainability of the organization.

It is important that healthcare organizations understand their contractual, administrative, and/or statutory rights to appeal such decisions. To effectively respond to such demands, it is critical to have an attorney with experience and knowledge of the various payors' appeals processes. Hashmi Law Group, PLLC, has developed a formulaic approach based on experience in health care law to respond to these issues. This approach accounts for the providers' interest while also effectively responding to government and commercial insurance's demands.

Why Hire An Attorney?

Health-care organizations need experienced legal representation that is willing to strongly defend the rights of providers. Our work in denial management for in-network and out-of-network providers facilitates effective and efficient conversations with government and commercial insurances, resulting in the most desirable outcomes for your organization.

Our experience includes assisting healthcare organizations in appealing denials, overpayment demands, offsets and recoupments, and other appeals relating to the following demands by:

  • Government – Zone Program Integrity Contractor (ZPIC), Recovery Audit Contractor (RAC), U.S. Department of Health and Human Services Office of Investigations, Novitas Solutions, Centers for Medicare & Medicaid Services, Health Integrity, LLC, Texas Medicaid & Healthcare Partnership, and others.
  • Commercial Insurances – United Healthcare, Cigna, Blue Cross Blue Shield, Aetna, Amerigroup, and more.

Have A Denial Or Overpayment Demand? Contact Our Firm.

The Hashmi Law Group, PLLC, in Dallas understands the urgency of matters such as denials, overpayment demands, and recoupment for health care providers. Therefore, our attorneys, based in Dallas, Texas, are available 24 hours a day, 7 days a week to answer your questions. Call 214-235-9938 or send the firm an email.

A consultation with one of our lawyers can help you understand your legal options and ease your concerns as you seek resolution of your legal issue.