"On-Site" Invasion (Audit) Prevented
Some health insurers use a tactic of demanding to come onto a doctor’s premises claiming that an “On-Site” audit is something that they have the right to perform. However, if the audit is not centered around quality concerns as to an in-network provider but rather is geared toward seeking ways to find billing issues and demanding money back, then QLG fights such on-site invasions.
Most in-network provider agreements have certain quality benchmarks that participating providers need to meet or exceed. While those provisions of the contract are enforceable, any provision in a participating provider’s contract that seeks to set payment terms or seeks to provide a basis for recoupment or repayment are overtaken and superseded by federal law, under ERISA.
So when a regional health insurer was literally banging on a medical practice’s door repeatedly, and making threats against the provider, Quadrino Law Group was hired to help. Numerous letters were written by the insurer giving deadlines for the doctor to capitulate.
Mr. Quadrino explained the legal concepts to the insurer regarding payment, repayment, and auditing and took the position that they an on-site “visit” was not in the cards, not legal, and could not take place.
The insurer let the matter go, stopped its demands, left the doctor alone, and continued to process all of its claims in the ordinary course and rendering payments.