New Jersey hospitals and healthcare providers face a myriad of challenges in securing proper payment for the valuable services they provide for their patients. Payers increasingly employ pre- and post-payment audits where diagnoses and procedures are changed or removed altogether, resulting in a reduction in the provider’s expected reimbursement. Payers tout their use of such “payment integrity” reviews to control costs and ensure regulatory compliance, however, the true objective is obvious – payers want to pay healthcare providers less.
The Human Element
Payers increasingly use algorithms to “data mine” claims for potential recoupments and AI to generate generic audit letters demanding refunds on so-called “overpayments.” On the healthcare provider side, many vendors tout state-of-the-art AI and proprietary software to automate the dispute process on the providers’ behalf. While AI has certainly shown itself to be a valuable tool for sorting data and identifying trends, algorithms and automation can only go so far. AI can only imitate what humans have done and create an imperfect facsimile, often with an incomplete understanding of pertinent facts and missing important nuance.
Can AI actually make a compelling case for a borderline diagnosis? Can AI understand the nuance in selecting between two competing principal diagnoses where the selection of one over the other could mean a difference of thousands of dollars in reimbursement?
The Costello Law Firm will re-humanize the payer dispute process for New Jersey hospitals and healthcare providers.
We believe the answer is not more AI, but reliance on the valuable human qualities of experience, discernment, persistence and advocacy. The Costello Law Firm will re-humanize the process of dealing with payer disputes on behalf of New Jersey hospitals and healthcare providers and ensuring correct payment by putting the power of aggressive and experienced healthcare provider advocates at your disposal.
Why Choose the Costello Law Firm?
Engaging a law firm may not be the first step to spring to mind when considering options to deal with a payer audit or reimbursement request. Why not just hire a team of coders and clinical staff to respond to the audits? First and foremost, the Costello Law Firm employs staff with many years of analyzing healthcare provider claims, medical records in a wide variety of specialties and advocating on the provider’s behalf to maximize reimbursement. Costello Law Firm also has staff with clinical experience and access to clinical experts and coding resources.
Advocacy & Experience
Presenting facts in the best and most persuasive light and building a concise and compelling argument around these facts is fundamental to the art of advocacy. Why not enlist an ally whose decades’ long stock and trade is healthcare provider advocacy? Attorneys are educated in and practice the art of advocacy every day. Attorneys are also bound by ethical principles to exercise their best efforts to zealously pursue the rights of their clients. That is the approach Costello Law Firm takes in serving New Jersey hospitals and medical providers. The attorneys at Costello Law Firm have over 50 years of combined experience advocating for healthcare providers.
In addition to advocating for New Jersey hospitals and healthcare providers on disputes with health insurance, the Costello Law Firm has decades of experience recovering medical expenses related to New Jersey Motor Vehicle Accidents (MVA) and Workers’ Compensation Recovery for hospitals and healthcare providers in New Jersey.
Health Insurance Disputes
The Costello Law Firm will advocate for New Jersey Hospitals and Healthcare Providers where underpayments and recoupments are the result of the following:
- DRG assignment
- Removing or re-coding ICD-10-CM diagnosis codes
- Removing or re-coding ICD-10-PCS procedure codes
- Change in principal diagnosis
- Severity of Illness (SOI) indicators
- “Place of Service” or “Level of Service” audits e.g. inpatient vs. outpatient
- Re-admission review
For New Jersey Hospital and Healthcare Provider health insurance disputes, Costello Law Firm will:
- Review the claim to determine if appeal is warranted
- Prepare appeal paperwork, including attaching pertinent medical records, and submit to the insurer through the appropriate internal appeal process
- Prepare any second-level or claim level appeals and submit same
- Once internal appeals processes are exhausted or the time for the payer to reconsider has passed, file available higher-level review.
Automobile and MVA Claims
For Automobile/MVA claims, the Costello Law Firm will pursue claims that are denied or unpaid due to the following:
- Lack of sufficient information or documentation to process the claim
- Patient not cooperating with the auto insurer’s coverage investigation
- Coverage dispute between two or more auto insurers
- Auto carrier states policy limits are “exhausted”
- Auto carrier is disputing causality or medical necessity of the submitted charges
- NJ-PLIGA claims
- MVA claims where the patient was struck and injured while riding an e-bike, scooter or other low-powered conveyances
- Patients injured while driving for or riding as a passenger with Uber/Lyft
- MVA claims where the auto policy designates health insurance as primary (patient designated Medicare or Medicaid as primary; auto insurer does not accept proof of submission to health insurance)
For New Jersey Hospital and Healthcare Provider Automobile/MVA disputes, Costello Law Firm will:
- Review the file to determine the reason for denial
- Conduct necessary investigation to ascertain proper source of payment
- Interact with the insurers’ claims representative and provide requested information or documentation
- Interact with NJ-PLIGA to assure proper notices are filed and paperwork submitted
- Contact patients for required information and completion of necessary paperwork
- Review “exhausted” claims for potential PIP policy expansion
- File all necessary appeals
- File litigation to compel payment, if necessary
New Jersey Workers Compensation Claims
For Workers Compensation Claims, the Costello Law Firm will pursue claims that are denied or unpaid due to the following:
- Bill denied due to lack of sufficient information or documentation to process the claim
- Workers Compensation carrier is disputing compensability of the claim
- Workers Compensation carrier is disputing causality or medical necessity of the submitted charges
- Workers Compensation carrier is disputing amount of reimbursement (i.e. “UCR” dispute)
For New Jersey Hospital and Healthcare Provider Workers Compensation disputes, Costello Law Firm will:
- Review the file to determine the reason for denial
- Pursue necessary investigation to ascertain proper source of payment
- Interact with the insurers’ claims representative and provide requested information or documentation
- Contact patients for required information and completion of necessary paperwork
- Handle all interactions with the Workers Compensation carrier on UCR disputes, including negotiating a compromise payment
- File litigation to compel payment, if necessary