QLG Persuades Major Health Insurer to Drop a $3.6 Million Claim Against A Radiology Firm For a Refund On Closed Claims

One of the largest privately owned radiology groups in the country sought Richard Quadrino’s assistance when a national health insurer was pressing for a $3.6 million refund on health plan claims it paid in the past. The insurer’s post payment audit staff alleged “overpayment” on a variety of tests that were performed by the radiology group’s professionals.

As is typical in circumstances where the medical provider is “in-network”, the health insurer relied upon the provider agreement that was signed by the radiology group as the basis for demanding a refund, alleging that the contract allows a retrospective audit and that the insurer has a right to repayment on claims that it believes it paid in error.

As Richard Quadrino has lectured and written about, however, there are ways to use ERISA to defeat the insurer’s contract claims and its alleged audits rights. In addition, Quadrino Law Group turned the tables on the insurer, seeking to audit the insurer, demanding its emails and internal documentation regarding its audit, investigation, and internal deliberations and communications regarding the large refund demand and its true motives for the request.

In a series of extensive correspondence, QLG demonstrated how the health insurer had waived its rights on the prior claims, violated certain applicable federal regulations, and could not rely upon the provider agreement to seek a refund. The insurer ultimately walked away from its demands, without any money being paid by Quadrino’s client.

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