Healthcare providers regularly undergo audits by insurers and government agencies, during which they must disclose their reimbursement related accounting records. As a law firm, PV Kent can assist in the audit itself. In cases where auditors cite questionable violations and overpayments, PV Kent has exceptional capability to challenge their findings. In many audit cases, we have significantly reduced — or even eliminated — alleged overpayments, fines, and sanctions based on the auditing entity’s review. Healthcare providers need to be aggressive in defending such auditing and related take-back efforts because the complexity and constant change in healthcare reimbursement often contributes to erroneous audit results.
In the event that administrative appeals for proper payment are exhausted, PV Kent attorneys can prosecute appeals before a variety of entities, including the Office of Medicaid’s Board of Hearings and the District and Superior Courts of both Massachusetts and New Hampshire. They have been successful in contesting non-payment due to:
- Pre-payment denials and post-payment recoupment
- Third-party liability and COB resolution
- Attempts by carriers to recover payments due to other insurance coverage identified after the fact.
- Improperly denied claims by Medicaid and other state agencies
- Administrative denials — by responding to state health contractors in accordance with strict program guidelines
- Third-party administrator and re-insurer denials
ERISA (Employee Retirement Income Security Act of 1974) specifies the federal standards for healthcare benefits payable under self-funded group health insurance plans. ERISA can be a minefield, but our experience in this area allows us to recover a significant number of improperly denied claims.
PV Kent attorneys navigate skillfully the complexity of ERISA regulations. For example, we work closely with third-party administrators, trustees, and re-insurers of ERISA plans to resolve issues without having to resort to unnecessary litigation. Our legal team can determine whether ERISA regulations preempt state insurance laws, expediently to avoid delays and unnecessary courses of action. We manage denials rigorously to effectively contest claims through all phases of the process, up to and including litigation.
As usual, PV Kent attorneys advocate, negotiate, and then litigate. In all cases, we complete all steps necessary to maximize revenue for healthcare providers. This includes making payment demands, notifying the Department of Labor of ERISA-plan violations, seeking noncompliance penalties, and recovering litigation costs.