Support for Audit Appeals & Defense

Has your client received a repayment demand?

If you’re an attorney who’s client has received a recoupment demand letter from Medicare, Medicaid or a private payer, you’ve come to the right place.

Many physicians are caught in the crossfire of the injustices prevalent in our current healthcare system. Government payers (Medicare and Medicaid) are providing financial incentives to contract auditors based on the amount of money they recoup. Equipped with sophisticated tools that they might not fully understand, these commission-based auditors attempt to recoup revenue that was legitimately earned by hard-working physicians. Commercial payers are riding the wave of this trend with their own recoupment programs. Our top priority is to help you protect physicians who have to contend with the increasingly systematic and aggressive tactics that some insurers use to improve their own profitability.

A winning strategy includes expert auditors

Gaining access to auditors experienced in the audit appeal defense process greatly increases the odds of successfully getting the demand reduced or eliminated entirely. The attorneys we serve had grown to trust our leaders as an extension of their defense team and gain access to a team of experts in auditing, coding and documentation, audit appeals and defense, medical necessity and regulatory compliance.

A History of Success

  • $11 million Medicare Refund Demand – Reduced to $3,000 and Payment Suspension Lifted
  • $14 million Medicare Refund Demand – Reduced to $233
  • Provider Served with 125-Year License Suspension – Case Dismissed and Provider Reinstated

Unbiased fact over interpretation – the missing link

There are many auditors out there who wrongly believe that medical coding is based on interpretation. This mistaken mindset becomes obvious, and actually gets magnified, when working in medical audit appeals defense. There are specific guidelines for medical coding and documentation, and auditors who use interpretation as an excuse for ambiguity in their auditing assessments and reports have no place in a defense strategy!

Our team works from fact. They strictly adhere to the most current guidelines and deliver reports/results that can be fully defended. They are protecting thousands or millions of dollars of physician revenue and leave no room for argument as to the medical necessity of services provided. You can rest assured that the audit has been performed in a way to help reduce the recoupment demand to as close to zero as possible!

Build your rock-solid defense strategy for your client

We arm you with facts to support a winning defense strategy. The audit reports you receive will demonstrate to the payer a deep understanding of the very system that is being used to demand revenue that was rightfully earned by your client. You’ll have no unexpected surprises and we work hard to ensure your case moves as smoothly and quickly as possible.

The DoctorsManagement Audit and Appeal Team Possesses:

  • A thorough understanding of the appeals and litigation process and comprehensive knowledge of federal and state laws, guidelines, statutes and regulation that steer the industry regarding compliance.
  • Extensive insight to the OIG, DOJ and AUSA as well as Central CMS (not the same as the MACs)
  • Relationships with government representatives including key members of the Congress and Senate (Senate Finance Committee), and Central CMS.
  • Use of language in communications that achieve results when requesting extensions as well as .
  • Communication skills that elicit response from government officials that cut through language that attempt to use their knowledge of the system and its loopholes to gain advantage.
  • Coding audit capabilities to review the claims in question (and provide a corrective action plan) using both attribute and variable statistical analysis to ensure proper samples are drawn.
  • Experience with focused reviews that balance both the quantifiable or “Medical Necessity” aspect with the qualified or clinical aspect of an audit.
  • Ability to question prohibited procedures that payers may be attempting to use in a concealed manner.
  • Multiple certifications and workflow procedures that include some of most comprehensive QA processes to validate audit findings.
  • Ability to present executive summaries that concisely outline audit results for each situation identified as well as comprehensive reports that are used in Civil Investigative Demands (CIDs / Interrogatories), State and Federal Hearings and for attorneys representing health care providers that are in need of independent and objective subject matter expert guidance.

Auditor Credentials:

  • Certified Professional Coder (CPC®) – an individual who has passed a coding certification examination sponsored by the American Academy of Professional Coders (AAPC).
  • Certified Professional Medical Auditor (CPMA®) – an individual who has passed an auditing certification exam sponsored by the American Academy of Professional Coders (AAPC).
  • Other, specialty certifications – (create a pop-up list of all the certs???)
  • National Alliance of Medical Auditing Specialists (NAMAS) – a division of DoctorsManagement, NAMAS provides ongoing support and training to DM’s auditing team as well as to auditing professionals across the country.
  • Access to ComplianceRiskAnalyzer™ (CRA) – CRA is a proprietary technology that accurately and rapidly identifies potential coding and billing compliance risks.

Contact us for a free consultation.

Call Us (800) 635-4040