Payment Disputes

We provide independent & objective opinions related to payment disputes

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B. Riley works with several national health plans serving as an extension of their SIU (Special Investigation Unit) department providing independent and objective opinions related to payment disputes. Analyses include review of medical records, claims data, licensure, accreditation, state and federal regulatory guidelines, as well as payer coverage and reimbursement policies. B. Riley can assist in maximizing over-payment recovery and reducing improper payments by leveraging our unsurpassed coding and claim expertise, as well as our extensive clinical knowledge to recover lost dollars due to improper payments.

Our range of health plan services supports the entire health plan spectrum, from local and regional managed care organizations to large, national health plans.

Overpayments may be a result of errors on the part of providers and/or payers. Examples of which include:

Payer:

  • An error calculating the allowable amount
  • An error calculating the deductible or co-insurance
  • A duplicate payment
  • An error in billing for the service
  • An ineligible patient
  • Making payment for care from an unauthorized provider
  • Making payment for a non-covered service or supply
  • Paying for a service that wasn't actually received by the patient
  • Payment made for services that weren't medically necessary

Provider:

  • A procedure or diagnosis coding error
  • Duplicate billing
  • An insurance verification error
  • Provider credentialing/enrollment errors
  • Scope of practice limitations, such as adherence to incident-to-guidelines
  • Medical necessity errors
  • Unbundling packaged procedures
  • Billing frequency errors
  • Billing for services not rendered
  • Failure to provide adequate medical record documentation to support services billed

B. Riley has extensive experience in reviewing over payment and recoupment appeals, providing independent and objective analysis of medical records, claims data, licensure, accreditation, state and federal regulatory guidelines, as well as payer coverage and reimbursement policies. We can opine on the validity of an over-payment determination. We also can supply expert witness testimony should a dispute rise to a higher level of scrutiny.