Private payers are becoming more aggressive with recoupments. When payers find a potential issue there are several strategies used to obtain recoupment quickly and easily from providers.
Payers will find and cite all available coding publications for support. Some of these coding publications are not official interpretations.
Payers might also cite coding guidance from specialty societies. This is fine except there may be misquotes and the cite may just be an informational article and not an official position. Even if a specialty society issues an official position, that does not mean that position is controlling.
The most important tool payers have is raising the issue of fraud in their recovery letters. Sometimes this is done because in states like California, fraud is required to recover back beyond a year. Fraud allegations also have the additional advantage of frightening many providers into settling.
The best thing providers can do is to fully review the coding issues, the authorities cited and craft a clear and reasoned response.