Health Plan Recoupment Defense and SIU Audits


About Course

Conference Material (Password Required)

The Webinar will discuss what recoupment and audit are, the reasons that insurance companies state are the reasons for the overpayments, and what steps should be taken to defend against the insurance company’s overpayment demands. The Webinar will address the ERISA obligations and protections and the importance of a provider obtaining a valid Assignment of Benefits. It will also set forth the notifications which must be sent out by the insurance company when it conducts an audit and seeks recoupment.

The Webinar will discuss the concept of full and fair review and that recoupment demands are considered “adverse benefit determinations”. It will advise the attendees of what information they are entitled to so that they can respond to and defend the audit findings and recoupment demands. The presenter will discuss various court cases on these issues and the most common basis for recoupments, such as services not covered under the plan or non-compliant.

The Webinar will go through what should be done when a provider receives an audit or overpayment demand, how to object, appeal, hire an expert and make document requests. It will also address the state insurance laws regarding time frames to request recoupments. Finally, it will discuss what happens when the insurance company does not comply with the ERISA demands.

Learning Objective

  • Learn how to respond to an audit and refund demand by never refunding money without demanding a written explanation for the recoupment and verifying its accuracy.
  • Learn about relevant court cases.
  • What to do if the insurance company does not comply with ERISA demands.
  • Importance of obtaining a valid and enforceable AOB
  • How to object to recoupment in writing.
  • How to make written ERISA Demands in objection letters.
  • Learn about state insurance laws and their time frames for seeking recoupment.

Areas Covered in the Session

  • How to Defend Against Insurance Company Recoupments, Repayment Demands, and SIU Audits
  • What is a 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
  • Is ERISA Demands are Not Met
  • If the Insurance Company Does Not Comply with ERISA Demands

Suggested Attendees

  • Physician
  • Nurses
  • Physician Assistants
  • Nurse Practitioners
  • Medical Assistants
  • Practice Manager
  • Office Managers
  • Billers
  • Coders
  • Auditors
  • CDI Specialists
  • Collection Staff
  • Front Desk
  • IT Specialists
  • HIPAA Privacy and Security officers.
  • Compliance Officers
  • Telemedicine System Vendors
  • Patient Accounts Personnel
  • Medical record supervisors
  • Health Information Management Administrators and Technicians
  • Other Personnel Interested in Billing Privileges with the Medicare Program

About the Presenter

Dreama Sloan-Kelly, MD, CCS has over 18 years of experience in the medical field. A graduate of Wellesley College and Tufts University School of Medicine she has a varied background including clinical, billing, and coding. Dreama is President/CEO of Kelly, Sloan, and Associates, LLC and speaks at various seminars and webinars, imparting her knowledge in an upbeat, matter-of-fact, manner. Her goal is to provide pertinent information to the attendee, minimize the nonsense, and make sure everyone has fun at the same time. Dreama works with practices one on one, through coding consulting. She offers in-services seminars that can be held on or off-site. Dreama has learned in most seminars you spend a whole day only getting 20% of what you need, and 80% you leave- she has made it her goal to carve out the 20% that you need and give you the take-home message that will help you and your practice.

Course Content

You can access all the webinar materials after successful payment

  • Webinar Link + Handouts PDF
  • Course Key
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