POST-PAYMENT MEDICAL NECESSITY DEFENSE

Commercial Insurance Recoupment & Retroactive Denials

Has your program received notice that a commercial payer intends to recoup funds for previously approved services?

When private insurers retroactively review Detox, Residential, PHP, or IOP services and issue adverse determinations, financial exposure can escalate quickly, particularly in multi-case chart audits.

I provide structured medical necessity analysis and appeal development for mental health and substance use treatment programs facing post-payment reviews and recoupment demands from commercial payers such as Cigna and Aetna.

BEST SUITED FOR:

  • Programs that were previously authorized and paid
  • Facilities facing multi-case chart pulls
  • Retroactive "does not meet criteria" determinations
  • Six-figure financial exposure tied to medical necessity

WHAT I PROVIDE

  • Detailed analysis of post-payment determination letters
  • Comprehensive defensibility review of records
  • ASAM/LOCUS based continued stay evaluation
  • Criteria-based appeal letter drafting
  • Strategic consultation to prioritize cases and reduce exposure
***This service focuses exclusively on medical necessity defense for higher levels of care. It does not include billing code compliance audits or regulatory documentation review.***

FREQUENTLY ASKED QUESTIONS

1. What is a post-payment medical necessity review?

A post-payment review occurs when a commercial payer re-evaluates previously reimbursed services to determine whether documentation supports the level of care billed. If the payer determines medical necessity was not sufficiently demonstrated, funds may be subject to recoupment.

2. What does the engagement process look like?
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All cases begin with a defensibility review of the denial letter and medical records. Appeal drafting services are available following assessment.

3. Who signs and submits the appeal?

Appeals are submitted by the contracted provider entity. I provide clinical documentation analysis and appeal drafting support; final submission and communication with the payer remain the responsibility of the facility.

4. Do you guarantee overturns?

No. Payor decisions are ultimately at their discretion. My role is to analyze documentation, assess defendability, and develop the strongest defensible clinical argument possible.

5. Do you assist with multi-case chart audits?

Yes. I provide structured defensibility assessments for single cases or multi-case chart pulls where financial exposure may involve multiple members or extended dates of service.

6. Do you assist with billing code audits?

No. This service focuses exclusively on medical necessity appeals for Detox through IOP levels of care.

7. What information do you need to begin?
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I will need the denial determination letter, dates of service under review, the complete medical record for the specified period, and appeal deadline.