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
    • Providers
    • Hospitals
    • Medical Groups
    • Beneficiary (Patient Balance)
    • Non-covered Services
    • Medical Necessity Denials
    • Drug coverage
  • Coverage issues
  • Underpayments
  • 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