Know your rights when payers try to recoup payments - DoctorsManagement Know your rights when payers try to recoup payments - DoctorsManagement

Know your rights when payers try to recoup payments

Before your practice pays back any money following a recoupment demand from an insurance plan, make sure your rights are protected, and don’t fall victim to payer scare tactics.

That’s the message from Thomas Force, expert healthcare attorney and president and founder of The Force Group, a healthcare revenue recovery and advocacy company based in Lindenhurst, N.Y.

Force, who has served as chief compliance officer for a health insurer, will share his strategies for how to defend yourself against commercial insurer audits at the upcoming NAMAS Conference from Dec. 6 through Dec. 9 in Nashville, Tenn.

  • However the insurance plan approaches you to try to get you to pay back money, Force says to remember that the Employee Retirement Income Security Act of 1974 (ERISA) affords you certain rights during the recoupment process, including:
  • Written notice with the specific reason for the audit and recoupment;
  • Written notice that you have the right to review all relevant claim documents and materials without charge; and
  • Written notice of the specific plan provisions on which the repayment determination is based, including references to specific plan documents and citations of exclusions.

That’s not all, according to Force. As the recoupment process is an adverse benefit determination against the provider, you’ve got the right to review material relevant to the recoupment determination, including internal emails and documents the plan used to make the determination.

Private payers are seeing the amount of money Medicare and Medicaid plans are recouping from providers, and they’re becoming more aggressive than ever in going after repayment demands.

In addition, new technology is ensuring that all private payers are getting much more detailed information about all provider claims, including repayment demands made by other providers. That’s why it’s more important than ever that you know your rights, and you’re able to protect your practice’s bottom line from aggressive recoupment demands from commercial payers.

Tom Force will talk about your rights, as well as the tactics that have made him so successful advocating for physician practices at the NAMAS Conference in Nashville starting on Dec. 6. Don’t miss this opportunity! See the entire agenda and register today at

-Scott Kraft, CPC, CPMA ( The author is an Auditor and Consultant at DoctorsManagement.