How to Defend Against Insurance Company Recoupments, Repayment Demands, and SIU 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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60 Mins
Thomas J. Force, Esq.

Navigating Insurance Payer Recoupments and Audits: Protecting Out-of-Network Providers

Out of network (OON), providers keep facing recoupment, refund demand, and so-called special investigations (SIUs) from insurance payers and health plans. If you are an out-of-network provider, it is imperative that you balance bill your patients for the difference between charge and payment. 

This webinar will delve into the core concepts of recoupment and audit, shedding light on the reasons cited by insurance companies for overpayments. Our expert speaker, Thomas J. Force, Esq. will guide you through the essential steps to effectively defend against insurance companies' overpayment demands. He will cover the obligations and protections outlined by the Employee Retirement Income Security Act (ERISA) and emphasize the significance of obtaining a valid Assignment of Benefits.

Furthermore, we will explore the required notifications that insurance companies must provide when conducting audits and seeking recoupment. By understanding these notifications and your rights, you can navigate the process more confidently. Our experienced presenters will draw upon their extensive knowledge and real-world examples to provide practical strategies for responding to and defending against audit findings and overpayment demands.

Join us for a power-packed 60-minute webinar featuring industry veteran Thomas J. Force, ESQ., renowned for his expertise in navigating recoupment demands, audit findings, and adverse benefit determinations faced by out-of-network (OON) providers. Thomas will provide invaluable insights into the concept of full and fair review, empowering attendees to effectively respond to and defend against insurance companies' recoupment demands.

During this engaging session, Thomas will shed light on the information that providers are entitled to, enabling them to mount a strong defense against audit findings and recoupment demands. Drawing upon his vast experience and in-depth understanding of court cases, Thomas will delve into the most common bases for recoupments, such as services not covered under the plan or non-compliance.

With a focus on the concept of adverse benefit determinations, Thomas will navigate the complexities of insurance payer practices, ensuring attendees grasp the nuances of recoupment processes. By unveiling the secrets of successful defenses, Thomas will equip OON providers with the strategies needed to protect their practice and financial well-being.

Webinar Objectives

After attending this webinar, participants will learn:

  • How to respond to an audit and refund demand by never refunding money without demanding a written explanation for the recoupment.
  • How to respond to an audit and refund demand by verifying its accuracy.
  • How to object to a recoupment in writing.
  • About relevant court cases. 
  • How to make written ERISA Demands in objection letters.
  • What to do if the insurance company does not comply with ERISA demands. 
  • About relevant state insurance laws. 
  • The time frames for seeking recoupment.
  • About the importance of obtaining a valid and enforceable AOB. 
  • About mandatory information which must be provided to them during an audit.

Webinar Agenda

  • How to Defend Against Insurance Company Recoupments, Repayment Demands, and SIU Audits
  • What is Recoupment?
  • Characteristics of Recoupment Letter
  • Understanding Basic ERISA Obligations
  • Full and Fair Review
  • Recent Court Cases
  • Importance of obtaining Valid and Enforceable AOBs
  • When faced with a Recoupment
  • Unsupported Services
  • Interplay with Insurance Law
  • Are ERISA Demands are Not Met
  • If the Insurance Company Does Not Comply with ERISA Demands

Webinar Highlights

  • What should be done when a provider receives an audit or overpayment demand,
  • How to object, appeal, hire an expert, and make document requests. 
  • The state insurance laws regarding time frames to request recoupments. 
  • What happens when the insurance company does not comply with the ERISA demands.

Who Should Attend

  • In and Out of Network Providers
  • Medical Billing Companies
  • Providers’ Office Staff
  • Physician, Facilities
  • Healthcare attorneys
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