Mathew Levy, Esq. and his associate, Stephen Cucolo, Esq. successfully reduced an overpayment demand issued to an Applied Behavioral Health (ABA) provider. Upon receipt of the audit and investigation from their client, the insurance company had determined a 100% error rate and demanded a $700,000 repayment.
After submitting an appeal, the overpayment determination was completely reduced from a 100% error rate to just 0% with the total repayment lowered to $0.
In addition, we were able to have the extrapolation removed because the error rate fell below 50% and through appeal and coordination with the plan were successful in challenging the findings and having the overpayment reduced to zero. The codes were 97153 and 97154 for adaptive behavior treatment and group adaptive behavior treatment for children with autism spectrum disorder. The plan denied the claims alleging improper documentation and failure to support the level of care being billed. We were able to argue that the plan had misapplied the relevant coding guidelines and failed to consider the medical records in their entirety which clearly demonstrated that the services were necessary and justified by the notes.
