Rivet Health Law practice addresses the full spectrum of healthcare and reimbursement matters involving government and commercial payors.
Payors (Government and Commercial)
Payors routinely audit providers and they often require pre-payment claim reviews before issuing payment. Any payor audit can create financial challenges for healthcare providers. Rivet Health Law is equipped to respond to payor audits from start to finish. Payor reimbursement matters that begin with a seemingly simple audit letter tend to become convoluted and require nuanced understanding of policy guidance and contract terms within the context of proper assignment of ICD-10-CM, ICD-10-PCS, CPT®, and HCPCS codes. Rivet Health Law attorneys have extensive operational experience with coding, audits, and appeals. This enables us to recognize and address important, often-overlooked details that can affect the outcome of an audit.
Our practice areas include:
- Payor Audits
- Target, Probe, Educate (TPE)
- Comprehensive Error Rate Testing (CERT)
- Recovery Audit Contractor (RAC)
- Unified Program Integrity Contractor (UPIC)
- Zone Program Integrity Contractor (ZPIC)
- Commercial Payor Audits
- Payor and Insurance Appeals
- Health Insurance Denials
- Medical Groups
- Beneficiary (Patient Balance)
- Non-covered Services
- Medical Necessity Denials
- Drug coverage
- Coverage issues
- Medicaid Billing Requirements
- Centers for Medicare & Medicaid Services Regulatory Requirements
- Claims processing
- Documentation requirements
- Billing Requirements
- ZPIC and UPIC
- Federal Health Benefits Regulatory Requirements
- Government and Third-party Payor Audit Response
- Third-Party Payor Audit Advice
Appeals Drafting and Responding to Payors (Overpayments)
Healthcare providers all too often mistakenly rely on staff who are ill-equipped to identify and address legal issues, and thus who are neither well-versed nor experienced in drafting and responding to appeals, to perform these critical tasks. Much is at stake when overpayments occur and providers seek to offset claims or request repayment.
Overpayments require timely and well-drafted responses and appeals. This entails far more than simply reviewing coding, billing, and medical records. It requires expertise that comes from knowing payor policies, audit notice requirements, critical contract provisions, understanding payor audit processes, state laws, and facilitation of timely and effective action.
Coding and Billing
Coding and billing are at the core of reimbursement. Rivet Health Laws founders Joseph Rivet and Heather Bowens had long and distinguished careers in health care administration before they became attorneys. Their expertise with respect to coding guidelines, coding conventions, billing, and practical application of CPT®, HCPCS, and ICD-10-CM, and ICD-10-PCS provides invaluable insight in the following practice areas:
- Compliant Coding and Billing
- Payor Requirements
- Modifier Compliance
- Rebilling/Correct Claim Issues
- Place of Service
- Drug Coding
- Durable Medical Equipment Coding
- Emergency Medical Services Coding
Evaluation and Management
Rivet Health Law founder, Joseph Rivet, Esq. is the author of Evaluation and Management Services: A Step-By-Step Guide to Accurate Coding, Reimbursement, and Compliance. His next book on evaluation and management (E/M) coding scheduled for publication in January 2021, will help providers across the health care landscape better understand and prepare for ever-increasing payor audits and scrutiny. Navigating the numerous and complex rules and payor requirements is challenging, especially because Medicare Administrative Contractors (MAC) continue to enjoy latitude with respect to documentation requirements when determining E/M levels.
Proactive audits can help healthcare providers determine whether their documentation is sufficient to support E/M coding in claims submitted. MACs often misinterpret Centers for Medicare & Medicaid Services (CMS) directives and seem to create their own rules when auditing E/M services, which results in overpayment demands for providers. Rivet Health Law provides thorough medical record documentation reviews and advice to help providers navigate payor inquiries and Target Probe and Educate (TPE), pre-payment, and post-payment E/M audits.
Due Diligence Transactions
Mergers and acquisitions (M&A) in the health care industry are complicated and many issues can emerge during the diligence process, such as Stark Law implications, anti-kickback safe harbors, and Health Insurance Portability and Accountability Act (HIPAA) compliance issues. M&As require a team of professionals ranging from private equity firms, management team, attorneys, and other skilled professionals to fully analyze a potential acquisition through proper diligence. Our firm works directly with investors and client attorney’s to evaluate coding, billing, documentation, and compliance operations, and help identify potential risk areas with the transaction. We are an objective view and know exactly where to look for weaknesses to help identify potential regulatory exposure and risk.
While many firms handle merger and acquisitions, our place in the process is to provide the subset of knowledge in the reimbursement and compliance space. Through this process our findings help clients understand potential risks they might be acquiring, establish a reasonable amount to put into escrow, and negotiating a purchase price.
Our team understands the health care business and how it operates, particularly, within revenue cycle, compliance, and health information management. We can help identify and interview key roles that go beyond the commonly identified organizational leaders. Our team has worked in health care operations and knows the technical questions to ask with coding, billing, health information and compliance to help identify any potential risks or compliance issues.
Health care is one of the most regulated industries in our nation. The stream of regulations can be difficult to manage, keep current, and ensure compliance. We help providers and practices understand and navigate the laws, rules, and regulations impacting health care operations.
Our Regulatory Guidance practice includes:
- Compliance with Medicare, Medicaid, and Commercial payor coding and billing requirements
- Compliance audits and development of compliance plans
- HIPAA compliance including policy creation or review, education, legal analysis, and handling Office of Civil Rights (ORC) audits and inquiries
Compliance in health care must fit the unique operations of each client. We offer a customized approach to understand your business operations to ensure all relevant areas of compliance requirements are met. We do not take a boiler plate approach.
Rivet Health Law compliance services range from functioning as outside compliance counsel to creating a compliance structure that fits the operations of our clients which is sustainable. We assess current compliance operations to building them from the ground up. Our approach is a partnership to ensure the compliance structure fits the business.
Our Compliance practice includes:
- Serving as outside Compliance Counsel
- Operating as an interim Compliance and/or Privacy Officer
- Performing Compliance Assessments
- Providing Compliance Guidance to business leaders and Boards
- Providing Regulatory Compliance updates to clients
Obtaining proper reimbursement from payors is critical. It should never be assumed payors properly adjudicate claims per contract rates. We help clients with a wide range of reimbursement matters. Rules and regulations can quickly change, and we bring the skills and expertise to our clients to handle such changes.
Our Reimbursement practice includes:
- Representing clients related to Balance Billing Mediation
- Payor reimbursement disputes and settlements
- Incorrectly adjudicated claims
- Telehealth reimbursement matters
- Interpreting Proposed and Final Rules impacting reimbursement
- Interpreting State Laws and Reimbursement Policies
- Drafting reimbursement analysis to payors for new services, procedures, and medical devices
Health care changes ranging from how care is delivered, self-registration, electronic health records (EHRs), and modernization of data capture through portable devices have all impacted revenue cycle which cannot be denied. Complexities are further compounded with rules and regulations directly impacting revenue cycle operations. We assist clients in understand laws, regulations, and policies and the impact they have on revenue cycle.
Our Revenue Cycle practice includes:
- Vendor Contract Reviews / Drafting
- Providing guidance
- Advising on revenue cycle configuration (claims systems)
- Securing Payment from Payors and responsible Third Parties
- Securing denial reversals
- Determining Reasonable and Customary Charges
Health Plans & TPAs
Health Plans and Third-Party Administrators (TPAs) face many challenges from controlling costs, developing competitive products, providing efficient and cost-effective service, and offering affordable insurance to the members they serve. There are constant pressures to minimize costs yet remain market competitive to employers and members.
Rivet Health Law assists Health Plans and TPAs to manage costs while remaining compliant with contract requirements specific to auditing, monitoring, fraud, waste, and abuse (FWA), and claims processing. The founding attorney of Rivet Health Law is steeped in experience formally building and creating FWA infrastructure and SIU units.
Our Health Plan and TPA practice includes:
- Developing Fraud, Waste and Abuse Manual
- Reimbursement, pricing, and billing matters
- Statutory and Regulatory analysis
- Medicare Program Audits
- Risk Adjustment Data Validation Audits
- Medicaid Audits
- Commercial Audits
- Develop FWA / SIU structure
- Develop and Review Policies
- Claims Data Analytics
- Development of Claims Edits
- Administering Contract Compliance Requirements specific to:
- Claims Audits
- Government Reporting Requirements
- Reviewing and providing Appeals Determination
- Assisting Contracting with Reimbursement and Claims matters
- Assisting Provider Relations with Provider Education and drafting Communications
Physician & Mid-level Provider Agreements
Before signing an employment agreement, it is crucial to have it reviewed by an experienced attorney who understands the marketplace and various traps that may be buried in the agreement. The anatomy of an employment agreement can be complicated and could results in oppressive restrictions when employment ends. There is no such thing as a “standard agreement.”
Our provider agreement practice includes:
- Reviewing the employment agreement and identify areas to consider to be addressed such as:
- Covenants Not to Compete
- Termination of the Employment Agreement
- Assignment of Professional Fees and Billing
- Restrictive Covenants
- Dispute Resolution
- Professional Liability Insurance including Tail Coverage
- Employer Paid or Reimbursed Expenses
- Assist in negotiating the terms of the offer directly with the prospective employer
- Drafting agreements
Having an attorney help review and understand the terms presented are critical prior to signing the agreement.
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