Insurance delays, denied reimbursements, and aggressive audits are more than just administrative headaches, they threaten the financial health and stability of your healthcare practice. Whether dealing with Medicare, Medicaid, or commercial insurers, physicians and healthcare providers across Florida face growing pressure from payors that undervalue services and obstruct timely payment.
At Di Pietro Partners, our healthcare lawyers represent licensed medical professionals, group practices, and healthcare entities in complex reimbursement appeals, overpayment disputes, and administrative hearings involving both private insurers and government programs. If your practice is facing a post-payment audit, recoupment demand, or unjust denial, our team is here to protect your revenue and ensure fair treatment.
Please note: We do not handle cases for individual patients seeking coverage for personal medical care, in-home health services, or insurance benefits.
Common Types of Payor Disputes
We help healthcare clients with issues such as:
- Denied or underpaid claims
- Improper downcoding or bundling
- Medical necessity challenges
- Authorization denials
- Failure to follow contractual terms
- Balance billing and out-of-network payment issues
- Delayed payments or underpayments
Disputes may arise from initial claims or be triggered later through audits, record requests, or payment reviews.
Medicare & Medicaid Reimbursement Issues
Federal and state programs often scrutinize billing more aggressively than commercial plans. Common disputes include:
- Post-payment audits by MACs, RACs, ZPICs, or UPICs
- Statistical extrapolation leading to inflated overpayment demands
- Medical necessity denials for inpatient vs. outpatient care
- Appeals through ALJ (Administrative Law Judge) hearings or CMS
We represent providers through all phases – redetermination, reconsideration, ALJ hearings, and beyond.
Commercial Insurance Denials & Contract Disputes
Our firm also assists with:
- Enforcement of payment terms under provider contracts
- Negotiating with payors who deny coverage based on policy interpretations
- Appealing denials related to experimental/investigational treatments
- Out-of-network disputes involving UCR rate discrepancies or benefit denials
- Prompt-pay violations under Florida law
Overpayment Demands, Audits & Recoupment
Healthcare providers often face post-payment audits or recoupment demands that allege fraud, upcoding, or overutilization often based on flawed data or technical errors. We help:
- Challenge statistical sampling and extrapolation methodologies
- Respond to record requests and audit letters
- Negotiate settlements or payment plans
- File appeals and represent clients in hearings before government agencies or insurance review boards
Our Approach to Appeals & Negotiation
We combine legal, regulatory, and medical expertise to provide:
- Strategic pre-litigation negotiation to resolve claims early
- Technical review of CPT, ICD-10, and medical documentation
- Administrative hearing representation before DOAH, CMS, and ALJs
- Contract enforcement against noncompliant payors
- Proactive compliance advice to prevent future disputes
Why Choose Di Pietro Partners for Payor Disputes & Reimbursement Appeals
- Healthcare Law Focus: Our attorneys concentrate on representing healthcare providers
- Proven Negotiators & Litigators: We resolve most disputes outside court, but we’re fully prepared for litigation when needed.
- Medical Advisor On Staff: With a quadruple board-certified physician on our team, we understand both the clinical and legal side of healthcare claims.
- Statewide Representation: We represent physicians, group practices, hospitals, and surgery centers throughout Florida.
Frequently Asked Questions
Q. Can I appeal a claim denial from Medicare or Medicaid?
Yes. There are several stages of appeal, starting with redetermination and potentially advancing to an ALJ hearing or federal court, depending on the amount in controversy.
Q. How long do I have to appeal a commercial insurance denial?
Each insurer has its own timeline – often 60 to 180 days from the date of denial. It’s critical to act quickly and comply with the appeal process.
Q. Can an insurer recoup payments after they’ve been made?
Yes, but they must follow strict legal procedures. We help providers challenge unjust recoupment or negotiate repayment terms.
Q. What’s “statistical extrapolation” and is it legal?
Statistical extrapolation allows auditors to project alleged overpayments from a small sample to a larger claim set. It’s controversial but permitted under federal law if done correctly – we frequently challenge the math and methodology used.
Q. Do I need a lawyer for a reimbursement appeal?
While not always required, legal representation significantly increases your chances of success – especially if the appeal involves high-dollar claims, potential fraud implications, or administrative hearings.
Schedule a Consultation
If your medical practice or facility is facing delayed payments, unfair denials, or aggressive audits from commercial or government payors, don’t fight alone. Contact Di Pietro Partners today to protect your revenue and defend your right to reimbursement.