Fighting Back Against Recoupment, Special Investigation and Insurance Payor Audit

Course Description

Healthcare providers must know what recoupment and audits are; and what steps should be taken to defend against the insurance company’s overpayment demands. This webinar will address the ERISA obligations and protections and the importance of a provider obtaining a valid Assignment of Benefits. It will also set forth the notifications which must be sent out by the insurance company when it conducts an audit and seeks recoupment.

Attendees will learn how to properly and effectively defend itself from insurer audits, special investigations and refund demands. Mr. Force will unravel the complexities of healthcare audits and recoupment demands. Attendees will learn about provider rights under state and federal law and how to draft on effective response and appeal to such audits.

The Webinar will discuss the concept of full and fair review and that recoupment demands are considered “adverse benefit determinations”. It will advise the attendees of what information they are entitled to so that they can respond to and defend the audit findings and recoupment demands. The presenter will discuss various court cases on these issues and the most common basis for recoupments, such as services not covered under the plan or non-compliant.

Learning Outcomes

• Defining recoupment, audits and triggers 
• Understand healthcare provider rights under state Law
• Understand healthcare provider rights under federal law
• Draft effective Response and Appeal Letters
• Understand time frames for response and statute of limitation for litigations
• Use of Fair Debt Collection Practices
• Review real cases involving audits against providers
• Learn about relevant court cases
• How to make written ERISA Demands in objection letters
• What to do if the insurance company does not comply with ERISA demands
• Learn about state insurance laws and their time frames for seeking recoupment

Areas Covered in the Session:

• Identify, defend, object and appeal insurer
• What is Refund demand, special investigations and audits?
• Avoiding recoupment, penalties and Lawsuits
• Reconnaissance on Recoupment: The Whys and How's
• Decoding the SIU's Role in Recoupment
• Deciphering 'The Notice'
  • Understanding the Notice
  • Reclassifying Recoupment
  • Anatomy of an Adverse Determination
  • Regulatory Requirements
• Decoding Provider Rights: Laws & Regulations
  • Fully Insured Health Plans
  • Employer and Employee-Funded Plans
  • ERISA Plan via Insurance Network
• Regulatory Recap: State Recoupment Laws
• ERISA Regulations & Medicare Advantage Requirements
• The Force of Full and Fair Review
  • A Court's Ruling
  • Provider's Right
  • Claim Your Due
• Recent Battlefield: Peterson v. United Health Group Inc., 2019
  • Cross-Plan Offsetting Disallowed
  • Broad Authority Misinterpreted
  • Administrative Fiduciary Duty
• Recent Battlefield: Lutz Surgical Partners v Aetna, 2021
  • Fiduciary Duties
  • ERISA Section 404(a)
• Frontline Report: Quality Infusion Care Inc. v. Health Care Service Corp., 2010
  • Cross-Plan Offsetting Allowed
  • Commercial vs. ERISA
• Tactical Review: Premier v. United Healthcare, 2014
  • Adverse Benefit Determinations
  • Settlement Summary
• The Aftermath: What Does This Mean For You?
  • Citing Cases in Appeals
  • Detailed Investigation Required
  • Raising Objections
• The Hammer of Justice: Statutory Penalties Under ERISA
  • Noncompliance Consequences
  • Attorney Fees
  • Potential Additional Damages
• When ERISA Demands are Ignored: The Fallout
  • Delay Recoupment
  • Additional Consequences
  • Understanding Your Rights
• Strategic Communications: Crafting Cover Letters
  • In-Network or Out-of-Network
  • Potential Financial Liability
• Establishing Your Position: Standing to Appeal or Litigate
  • Provider Standing
  • Assignment Language
• Anti-Assignment Clauses and the Power of Attorney: Friends or Foes?
  • Anti-Assignment Clauses
  • Power of Attorney
• Field Study: American Orthopedic & Sports Med. v. Independence Blue Cross Blue Shield, 2018
  • Legal Distinction
  • Patient Dependence
• War Tactics: Contracting Strategies
  • Negotiating a Network Participation Agreement
  • Contract Breaches
• Your Weapon Against Injustice: The Fair Debt Collection Practices Act (FDCPA)
  • Copy Patient on Appeal Letters
  • Application of FDCPA
  • Penalties
• Live Q&A Sessions

Suggested Attendees:

• Healthcare CEOs
• Healthcare CFOs
• Healthcare COOs
• Healthcare Provider Revenue Cycle Staff
• Healthcare provider Office Managers and Billing Staff and Companies
• Healthcare Compliance Personnel
• Healthcare Attorneys
• Physicians
• Physician Assistants
• Nurse Practitioners
• Surgeons
• Hospitals and Other Facilities
• Insurance companies
• Healthcare Consultants
• Practice Manager
• In and Out of Network Providers
• Medical Billing Companies
• Providers Office Staff

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About the Presenter:

Thomas J. Force, ESQ., is a state and federally licensed attorney with over 34 years of experience in the healthcare and insurance industries. As a former U.S. Marine and a successful Wall Street insurance litigator, Mr. Force served as General Counsel for a New York-based Accident and Health Insurance Company, where he also served as Chief Compliance Officer. These experiences led to the founding of The Patriot Group.

Mr. Force is a nationally recognized expert in revenue collection techniques, appeal strategies, and healthcare compliance. He is on the Advisory Board at Hunter Business School, a New York-based school for medical billing and coding students.

Mr. Force is an active member and frequent speaker on managed care and collection techniques for the Health Finance Management Association, several state medical associations, and other healthcare organizations.

On March 29th, 2022, Thomas J. Force, J.D, Esq, President of The Patriot Group, served as moderator for the forum on Clinical Denial Management at Hofstra University, organized by the Health Finance Management Association – Metropolitan Section.

Additional Information

Snippets From Our Previous Session