Private Payer Reimbursement and Appeals

The business of our law firm is assisting healthcare providers. We represent doctors, doctor groups, doctor associations, healthcare centers, hospitals, healthcare professionals, elder care businesses, and other healthcare providers. In our Country’s third party payer system, reimbursement from third party payers is the lifeblood of many healthcare providers. Our law firm’s objective is to help healthcare providers keep the money they have earned by ensuring it is not arbitrarily denied by third party payers.

We Ensure Your Claims Are Not Arbitrarily Denied

Private Earned reimbursement is your money. Often the denial of a claim or group of claims is arbitrary rather than based on legitimate, objective standards. When the financial stakes are significant, our law firm can assist you in keeping the third party payer honest about how your claims are processed. Before you assume the denial of your claims cannot be successfully challenged, talk with us.

Generally speaking, private third party payers provide coverage for services they deem “medically reasonable and necessary” for the diagnosis and/or treatment of a particular condition. Private payers may employ a variety of reimbursement methods to compensate doctors for services to covered beneficiaries, such as fee-for-service and capitation. Payers should rely on nationally recognized, objective coding guidelines and standards, but individual payers may employ particular tools that vary in how they process particular claims. Universally, private payers require that providers properly document patient medical records to support the utilization of medical services.

Billing Errors and Failure to Document

The primary causes of claim denials are technical billing errors and lack of documented medical necessity. Billing errors can derive from sloppy administrative mistakes or omitting to list the right diagnosis code. Medical necessity denials happen when an insurer contends a procedure is experimental or the documentation of medical necessity is lacking. In either event, the appeals process is the provider’s opportunity to put the subject claims(s) in the proper light and demonstrate why the denial is improper. The objective is simple and straightforward: to obtain revenue that has been earned. Unfortunately, the process is not always simple or dependable. While many appeals can and should be handled in house, without the assistance of a lawyer, where significant money or stakes (e.g. setting a precedent with the payer) are involved, utilizing counsel should be considered.

Atlanta, Augusta, Aiken Reimbursement Appeals Law Firm

Our law firm has demonstrated its commitment to helping healthcare providers succeed. We want to help your healthcare business prosper, make more money, and avoid legal pitfalls that result in lost revenue or significant expense.

We Will Enhance and Protect Your Revenue

As a law firm, our objective is to advance the financial interests of physician practices and other healthcare businesses. We have offices in Atlanta and Augusta, Georgia. Call us at (404) 685-1662 (Atlanta) or (706) 722-7886 (Augusta and Aiken). One of our staff will schedule a free, confidential evaluation for you.