Reimbursement disputes involve denied claims, downcoded payments, recoupment of prior payments, and disagreements over contract rate application. They may proceed through administrative appeals, arbitration, or litigation depending on the payer.
Medicare disputes follow a defined multi-level appeal process.
Alternative Names:
Reimbursement Dispute, Payment Dispute
Why it Matters?
Exhaustion of administrative remedies is the threshold issue in government payer disputes, since Medicare and Medicaid claims must proceed through the statutory appeal levels before judicial review. Commercial disputes turn on the provider agreement, which frequently includes arbitration provisions and short notice periods for contesting payments. Extrapolation from audit samples is a recurring flashpoint where a small sample produces a large recoupment demand.
Frequently Confused with
Related terms
Frequently asked questions
Must administrative remedies be exhausted?
What is extrapolation?
