June 7, 2017
Chicago partner Edwin Brooks and associate Jason Mayer wrote an article for the May 2017 newsletter of the American Health Lawyers Association’s Health Care Liability & Litigation Practice Group, discussing recovery actions against providers who have been overpaid for medical claims.
In the article, Brooks and Mayer noted that overpayment recovery cases against providers can be very beneficial, yielding a return on investment of $11 to $1, and that both the government and private health plans are making greater use of it.
Still, the authors advised against rushing into overpayment recoveries. The article identified risks that overpayment claims entail from the provider and health plan perspectives and cautioned that they be “thoroughly vetted before action is taken.”
Plans, the authors wrote, “should have policies and a provider manual that discuss the plan’s procedures for overpayment recoveries that are consistent with federal and state law” and contractual requirements of providers and the government. They should also ensure that provider agreements support the plan’s right to audit providers and recover overpayments when they find them.
The article also reviewed provider defenses against clawback actions, including laws that most states have that compel health plans to follow certain procedures in identifying and recouping overpayments.