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Are you having problems with your managed care or health insurance company?

Healthcare providers:

  • Have you been denied payment for your services?
  • Are your bills being refused due to level of care billed, medical necessity, no record date, no plan of care, or illegible records?
  • Are you losing appeals?
  • Are you currently under investigation for billing issues?
  • Is the managed care plan using sampling methodology for overpayment recovery?
  • Has the insurance company “extrapolated” their sample to recoup their overpayments?
  • Has the insurer decided on future payment recovery to recoup their so called overpayments?
  • Are you having problems with “incentive programs”?


What options do you have when managed care or health insurance companies challenge your billing? Health insurance companies and managed care providers look very carefully at bills provided by doctors and healthcare providers. They have many reasons to challenge the amount of money billed by a doctor for the services provided. Some examples include: services were not a medical necessity, that the level of care billed was higher than the level of care actually provided, or that the records were illegible.

Insurance providers use many methods in order to try to not pay doctors what they are owed. It may be a technicality such as no date on the record, or a more serious discrepancy such as the doctor does not lay out a specific plan of care for the patient.

These companies are allowed to use sampling methodology in their “overpayment recovery.” The insurance company often will extrapolate when coming to the amount of money that they believe is an overpayment. Extrapolate is exactly what it sounds like. The insurance company uses a methodology to look at a small part of the bills and then decides what the actual overpayment is—based upon this extrapolation. This methodology can be challenged successfully to reduce the amount of the alleged overpayment. Insurance companies also use incentive programs in order to try and have doctors reduce the care provided. These can also be challenged. Often the auditors who review these bills and these methods for insurance companies use flawed methods and analyses to come to their numbers.

Sometimes doctors will appeal these billing challenges on their own. But often it is a better idea to have an attorney experienced in dealing with managed care and health insurance companies to assist you.

If you are a medical provider and your bills are being challenged, this could have a very large financial impact on your business. Often these challenges are far in excess of $100,000.

For a law firm experienced in fighting the insurance companies on behalf of hard working healthcare providers, please contact ThePhillyLawyers today.


  • Are you having problems with your managed care or health insurance company?
  • Is your health plan withholding payments due to services that are deemed “not medically necessary”?
  • Are you forced to pay doctor bills that should have been paid by your health plan?
  • Are you being investigated for healthcare fraud?
  • Is your healthcare provider notifying you of coverage stoppage?

An expert team at ThePhillyLawyers will guide you through the healthcare maze and help you with your battles. We can assist medical providers and patients with all of your healthcare reimbursement issues. We will present a well-researched, organized defense, to stop insurance companies from taking your money. Whether you are a provider or a patient, we can help you today.


A helpful definition of terms:

Denied services: The insurance company has criteria that it uses to determine whether or not you qualify for a product or service. They have the ability to deny coverage if they don't have clinical evidence to approve the request.

Level of care: Insurance companies are able to reduce payments if you are billing for a higher level of care than they deem appropriate. Criteria must be met for higher levels of care.

Medical necessity: If a specific set of medical criteria are not met the insurance company can refuse payment for being “not medically necessary.” A doctor may request an MRI for a strained shoulder without recommending physical therapy first. Often, additional clinical information will help overturn the denial on appeal.

Illegible records: Older physicians may still write clinical records. If the notes are difficult to interpret the claim may be denied. It is recommended that clinical notes are electronically recorded.

Appeals: Providers and patients have the right to an appeal if a claim is denied. The insurance company devotes many resources to the appeals department. The appeal must be completed in a specific sequence with the required documentation. The specifics of an appeal are easily obtained by a denial letter or with a simple phone call.

Sampling methodology: An insurance carrier can audit your claims by choosing a small group of submitted claims and reviewing them. Upon review of the “sample” they are allowed by law to base a recovery of presumed overpayment from that sample.

Extrapolated recovery: The insurance carrier is allowed to estimate a percentage determined by a sample and multiply it by the number of claims submitted in a time period, to estimate a recovery amount. This extrapolation can reach $100,000 and above.

Overpayments: Insurance carriers may extrapolate a sample error and compute an amount they feel you are overpaid. They recover huge amounts of estimated overpayments annually.

Incentive programs: An insurance carrier may design a special billing process for a predetermined group of patients. An auditor may make an error in reviewing this different style claim.

Healthcare Fraud: Intentionally billing for products or services not provided.