What We Do
Wolfe Pincavage regularly assists provider clients with maximizing recovery of underpaid and denied healthcare claims.
Our multidisciplinary team often serves as an extension of the client internal revenue cycle team to improve denials management.
We leverage our sophisticated managed care expertise and industry relationships to successfully resolve complex denials, underpayments, plan audits and overpayments, without litigation or arbitration. Our team has prevailed and eliminated overpayment demands, while assisting clients in defending against health plan audits and recoupment activity.
Our recovery techniques have proven to be highly effective, resulting in millions of dollars recovered for our provider clients. We tailor our approach to each provider clients’ denials management needs, and use technology to diagnose and treat systemic issues that our provider clients are facing.
Technology
- Proprietary software
- Analysis and Strategy – We use proprietary software to analyze our provider clients’ claims data and identify trends in denials and underpayments. Our complex claims team – comprised of attorneys and healthcare professionals – develops a strategy for recovery that is specific to each clients’ needs.
- Solutions – We provide solutions that our provider clients can implement.
- Reporting – We create custom reports based on our provider clients’ requests to assist in the denials management process.
Specialty Team
Our firm’s multidisciplinary team uses its extensive legal, clinical, and revenue cycle expertise to resolve complex claims matters. We partner with our provider clients’ revenue cycle teams, physician advisors, and industry experts to maximize recovery for our clients.
- Consists of Attorneys, nurses, claims analysts
- Partners with physician advisors and industry experts
Capabilities
Payor Disputes
Our multidisciplinary team resolves complex claim disputes when payors underpay and deny in- and out-of-network healthcare claims for various reasons. We challenge the implementation and application of health plan payment policies. We specialize in recovering payment from commercial healthcare plans, as well as managed Medicare and Medicaid plans.
- Administrative denials and underpayments
- General medical necessity denials and underpayments
- Coding issues
- Coordination of benefits issues
- Overpayment and recoupment activity
- Pre-and post-payment reviews of itemized bills, level of care and DRGs
- Health plan payment policy issues
- Non-covered and experimental denials
ERISA
Our clients rely on us to routinely pursue payment for healthcare goods and services from employee welfare benefit plans governed by ERISA.
No Surprises Act
Our firm is at the forefront of the federal No Surprises Act (the “NSA”). We provide education and consultation to our clients on the ever-changing rules surrounding the NSA, and are highly sought to speak on the topic before healthcare leaders throughout the U.S.. We engage in the Open Negotiation period and the federal Independent Dispute Resolution process on behalf of our clients to obtain payment for out-of-network services.
Medicare Appeals Process
We administratively appeal and contest reimbursement issues that create large-scale underpayment and denial trends for both in-network and out-of-network providers. We have expertise in challenging government denials and have pursued administrative appeals for Medicare, Medicaid, and Tricare claims.
Federal employee appeals process
Our firm provides education, consultation, and representation to our clients undergoing the appeals process for the Federal Employee Health Benefits Program.
Reference-based pricing
Our team is adept at challenging reimbursement rate limitations implemented by reference-based pricing plans. We offer creative legal solutions to recover underpaid amounts that meet our clients’ expectations and the fair market value for the services.
Compliance & Operational Counseling
- Rev-cycle process improvements – We identify and implement process improvements that avoid preventable denials and underpayments, and increase our provider clients’ revenue.
- Compliance – We assist our provider clients with implementing programs and creating policies for HIPAA, Privacy, and Part 2 compliance.
