February 01, 2018

Understanding, Avoiding and Navigating Third Party Pre-Payment Review Audits

Anthony S. Hearn, Ver Ploeg & Lumpkin, Miami, FL


The pre-payment review (PPR) audit can wreak havoc on a healthcare provider’s practice, creating cash flow shortfalls and other interruptions that negatively impact the delivery of care to patients. In addition to retrospective claims review and their attending overpayment requests, third party payors are increasingly relying on PPR audits as a tool to trim provider reimbursements. This article addresses the causes and legal basis for private payors’ use of such audits, state and federal legal limitations on their implementation, strategies for providers to limit their exposure to PPR audits, and what to do once subject to a PPR audit. 

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