Successfully manage overpayment demands

In-house and outside health care counsel routinely confront questions about how to handle overpayment demands from fiscal intermediaries and carriers. The lack of uniformity among these payers often makes this task even more complex, says Carrie Valiant, a health care attorney at the Washington, DC, office of Epstein Becker.

The ability of counsel to effectively respond to these demands is largely a function of when they learn about the problem. That is true for in-house lawyers as well, she says.

When providers receive a large documentation request, several steps can be taken at the front end, she says. While the initial demand often will notify the provider that it has 15 or 30 days to provide documentation, often that is not enough time. "You cannot do a good job of documentation in that short period of time," Valiant argues.

According to Valiant, the first thing providers should do is get an extension. "People are sometimes not thrilled about even asking for an extension because they feel it is admitting their documentation is not in order," she says. "But most carriers and intermediaries are very willing to give extensions to let you put the documentation together."

Another thing providers can do is examine the documentation to assure that everything is complete. Valiant says she routinely discovers a variety of documentation glitches, such as missing pages that were not copied from the patient record, forms with critical signatures on the backside that were not copied, and a lack of supporting documentation that may fall outside the patient record.

"Proof of delivery is not always in the patient record," she adds. Many times, audit requests are handled by people who simply copy the patient file and send it without reading the letter closely enough to realize that proof of delivery is required, she says.

Another thing that counsel can do at the front end is to make sure that providers are allocating sufficient resources to the overall effort, says Valiant. Many times, it is difficult to convince providers this is important, she adds. But allocating sufficient resources at the front end often means that a lot of claims are saved, she says.

Valiant says many providers deal with audits at "a rote level," when it is people higher up in the company who should be thinking about the bigger picture early in the process.

According to Valiant, it also makes sense to establish a dialogue between the client and the carrier when audit requests are received to help learn about ongoing issues. "I have had a lot of situations where people are basically saying the same words, but they are speaking a different language," she explains. "There is a disconnect and they do not understand what the other party is saying."

When providers begin a genuine dialogue rather than simply sending paper back and forth, they begin to understand exactly what the carrier requirement is, Valiant says. "It is often far different than what jumps off the printed page," she warns.

Valiant points out that carriers sometimes misread the manual. When that occurs, counsel should try to have the demand withdrawn, she suggests. "Think outside the box," she asserts, adding that demand letters are withdrawn with enough frequency to make that worth attempting. "They don’t always get it right."

Finally, Valiant says that providers should consider raising statistical sampling issues. "If there is a glaring error in the sampling, sometimes you can have the letter retracted," she says.

Many sampling issues are less contentious than before because carriers and intermediaries now are more educated about what will stand up at the appeals level, says Valiant. But she adds that it often makes sense to talk to a statistician to find out if there is a significant issue.