Recoupment Defense

We specialize in assessing the documentation & billing

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B. Riley specializes in assessing the documentation and billing for claims against payer guidelines, regulatory requirements and industry standards. From patient access through coding, claim submission and payment reconciliation, we offer end-to-end revenue cycle expertise. Our experienced professionals assist clients in successfully navigating the ever-changing coverage and reimbursement guidelines of both government and private payers, minimizing risk from regulatory exposure while maximizing efficiencies and collections.

B. Riley assists providers in responding to recoupment requests and over-payment demand letters. Recoupment is the recovery by Medicare of any Medicare debt by reducing present or future Medicare payments and applying the amount withheld to the indebtedness. Providers may also receive a recoupment request or over-payment demand letter from a private payer.

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 demands and recoupment requests on behalf of providers and conducting analysis including review of medical records, claims data, licensure, accreditation, state and federal regulatory guidelines, as well as payer coverage and reimbursement policies. We also can supply expert witness testimony should a dispute rise to a higher level of scrutiny.