When a payer comes after your reimbursements, we go first.
Audit defense is where most of our work goes. We file the response on your behalf, documented and evidenced, led by a CPC-certified coder.
From letter to resolution.
Five stages. You hand over the letter at the first one and stay informed through the rest. You do not have to become an expert in payer policy to get through this.
- 1
Letter received
You forward the payer’s audit notice or overpayment demand. Do not respond to it alone, and do not let the clock run. Every letter carries a response window, and it starts on the date the letter was issued.
- 2
Case review and scope
We establish exactly what is being questioned: which claims, which date range, which policy the payer is citing. Review turnaround: pending
- 3
Evidence and documentation assembly
We pull the encounters, the documentation supporting each code, and the payer’s own published policy for the period in question.
- 4
Rebuttal filed with the payer
A written response filed on your behalf: the policy cited back, an indexed record of supporting documentation, and the remedy we are asking for.
- 5
Resolution and prevention plan
Whatever the outcome, you get the coding or documentation changes that stop the same finding recurring.
What we actually argue.
A recovery demand arrives with a 30-day clock and a number on it. The number is almost never the amount you owe.
We argue the payer’s method as well as its findings.
A demand letter has two parts. There are the claim lines the payer disallowed, and there is the method it used to turn a small review into a large number. Most responses argue only the first part. The second part is usually where the money is.
When a payer reviews a sample and projects the result across your full claim volume, the projection does nearly all the work. A review of 73 claims can produce a demand covering 5,500. If the projection is unsound it comes off, and what is left is the actual dollar value of the disallowed claims inside the sample. That is normally a small fraction of the original demand, often under 5% of it, because the sample was a small fraction of the claim universe.
Sampling validity is testable. A commonly cited reference point for a defensible sample is around 10% of the claim population, and demands built on samples closer to 1% are not unusual. A sample that thin does not support a projection across the whole population.
Four kinds of finding, four different responses
A list of disallowed claims looks uniform. It is not, and treating it as one pile is how defensible claims get written off alongside indefensible ones.
Records not received
Administrative, not clinical. The claim was never reviewed on its merits because the documentation never reached the reviewer. Locating the record and submitting it resolves the finding outright. In audits driven by missing paperwork this is frequently the largest single category of exposure, and the cheapest to clear.
Documentation incomplete
The service happened and the note is thin. An advance care planning note that does not name which directives were discussed, or a timed telephone visit with no start and stop time, fails on completeness rather than on medical necessity. Supplying the fuller record recovers much of this.
Level of service disputed
The payer accepts that the visit happened and rejects the level billed. Argued on medical decision making where the documentation supports it, or on documented time where the guidance permits time-based code selection.
Genuinely unsupported
Some lines have no defense. We concede those and say so in the packet, which is a deliberate choice rather than a concession of the case. See the next point.
How the response gets built.
Four disciplines that decide the outcome
- 1
Cite the subsection, not the manual
A response that waves at CMS guidance in general loses. Payers reviewing evaluation and management levels commonly rely on CMS Claims Processing Manual Chapter 12, §30.6.1(A). Subsections (B) and (C) of the same section permit time-based selection where counseling or care coordination is a significant component of the visit. A payer applying (A) alone to a visit that (B) or (C) governs has applied the wrong test, and saying so with the citation attached is a different argument from asserting the level was correct.
- 2
Concede what cannot be defended
We do not contest every line. A response that fights everything invites the reviewer to discount everything, and the lines with genuinely strong documentation are the ones that suffer. Conceding the weak lines is what buys credibility for the strong ones, and the strong ones are where the recoverable money sits.
- 3
Reconcile the record against itself first
Payer follow-up review looks for internal contradictions and finds them if we have not: a note carrying two different time entries for one encounter, a billing provider of record who is not the signing provider, patient identifiers that disagree between the note header and the signature block. Each is cheap to fix before submission and expensive once the payer raises it.
- 4
Assume there is no second round
Appeal rights vary by payer and by line of business, and a number of payers issue a final determination once they have reviewed the first rebuttal, with no second-level option. We build the first submission as though it is the only one: line by line, every objection answered, every citation attached.
What this does not fix
Two lines of business inside the same audit, for the same practice and the same codes, can resolve very differently. Scrutiny and documentation expectations vary by payer and by plan type, and a strong result on a Medicaid line does not predict the same result on a commercial line.
Where the underlying record genuinely does not support the service billed, no appeal strategy recovers it. The recoverable portion of any demand is bounded by what the documentation will bear. Anyone telling you otherwise before reading your notes is selling you something.
The rebuttal, annotated.
This is the document the whole page is about. Format shown with details redacted. Every filing carries these three parts.
The payer’s own published policy, quoted back with the section number. The argument starts on their paper.
Every exhibit named and attached: encounter notes, the distinct assessment, the provider’s attestation.
Reversal in full and recoupment suspended pending review. We ask for it explicitly, because a remedy that is only implied gets ignored.
An AAPC-certified professional coder leads every case, with 8+ years in payer disputes behind them.
Questions practices ask when the letter arrives.
Send us the letter, and don’t reply to the payer on your own in the meantime. Audit and overpayment notices carry a response deadline that begins running from the date on the letter, and the most expensive mistakes we see are a missed window or an unconsidered first reply that concedes something it didn’t need to.
Pricing: pending Audit defense is included for practices on full-service RCM, and available as standalone project work otherwise. We’ll tell you the fee before any work starts, in writing.
Yes, and it’s common. We can take over a response already in progress, including one another biller started. What matters is how much of the response window is left. Send the letter and the correspondence so far, and we will tell you honestly whether we can still help.
A recoupment is not the end of the matter. Payers operate appeal processes with their own deadlines, and a completed recoupment can still be disputed through them. The realistic answer depends on the payer, the basis of the finding and how much time has passed. That is what the case review establishes.
An audit letter is a deadline. Start today.
Send us what the payer sent you. Before you commit to anything, we will tell you what it actually says, what the window is, and what we would file.