How to Effectively Handle Insurer Refund Demands and Special Investigation Audits

Thomas J. Force, Esq.

Thomas J. Force, Esq.

As a state and federally licensed attorney in both New Jersey and New York, Mr. Force has over 30 years of experience in the healthcare and insurance industries. His success as a Wall Street insurance litigator and his tenure as General Counsel for a New York-based Accident and Health Insurance Company where he served as Chief Compliance...
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August 21, 2024
01:00 PM ET | 12:00 PM CT
60 Mins

Insurance payer audits and special investigations can be daunting for healthcare providers. These audits often result in significant monetary demands, and navigating the complex legal landscape can be challenging. This comprehensive program, led by Thomas J. Force, Esq., provides a detailed blueprint for effectively managing insurance payer audits and special investigations. Attendees will gain invaluable insights into both state and federal laws and learn techniques to reduce or eliminate insurer monetary demands.

Webinar Objectives

The primary objective of this session is to equip attendees with the knowledge and skills necessary to prepare a compelling written appeal and objection letter to an insurance payer audit or refund demand. By the end of this session, attendees will have a robust understanding of strategies to defend against monetary demands effectively, with the goal of reducing or eliminating such demands.

Webinar Agenda

  • General Discussion and Definitions:
    • Introduction to insurance payer audits and special investigations.
    • Key terms and definitions relevant to the audit process.
  • High Stakes of Healthcare Audits:
    • Understanding the financial and operational impacts of payer audits.
    • The importance of a proactive approach to audit management.
  • Commercial versus Government Audits and Refund Demands:
    • Differences between commercial and government audits.
    • Specific challenges and strategies for each type of audit.
  • How Audits Begin and Health Insurer Strategies:
    • Common triggers for payer audits.
    • Tactics used by insurers during the audit process.
  • Decoding the Special Investigator’s Role:
    • Understanding the role and objectives of special investigators.
    • Strategies to effectively interact with investigators.
  • Deciphering the Notice Requirement:
    • Legal requirements for audit notices.
    • How to respond appropriately to audit notices.
  • Fully Insured versus Employer Funded versus In-Network versus Out-of-Network:
    • Differences in audit processes based on the type of insurance coverage.
    • Specific considerations for each type of coverage.
  • State and Federal Law:
    • Overview of relevant state and federal laws governing payer audits.
    • Key legal precedents and their implications.
  • Case Studies and Analysis:
    • Examination of real-life cases to highlight effective audit defense strategies.
    • Lessons learned from successful and unsuccessful audit defenses.
  • The Appeal and Objection Letter:
    • Detailed guide to drafting a persuasive appeal and objection letter.
    • Common pitfalls to avoid and best practices to follow.
  • Conclusions:
    • Summary of key takeaways from the session.
    • Final thoughts on preparing for and defending against payer audits.

Webinar Highlights

  • In-depth examination of state and federal laws relevant to payer audits.
  • Strategies to prepare an effective written appeal and objection letter.
  • Techniques to defend against audits and refund demands successfully.
  • Case studies and real-life examples to illustrate key points.

Who Should Attend

Healthcare attorneys, revenue cycle personnel for medical providers, healthcare facilities and medical practices, healthcare practitioners

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