Practice Enhancement

As part of the New Jersey Doctor-Patient Alliance Practice Enhancement Program, we are offering a billing optimization system that will protect you and your practice and enhance your monetary collections via a three-phase program:

PHASE I:Out-Of-Network Healthcare Reimbursement Compliance Program

PHASE II:Claims Appeals

PHASE III:Claims Litigation

PHASE 1Out-Of-Network Healthcare Reimbursement Compliance Program

This program works through fortifying your practice/ASC with policies and procedures that are consistent with federal guidelines, including ERISA, HIPAA, PPACA, and Department of Labor.

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  • Initiate a comprehensive practice review and consultation at a discounted rate for NJDPA members.
  • Identify deficiencies and/or vulnerabilities in your reimbursement process due to missing or incomplete documentation or data.
  • Implement a compliance program consistent with federal law and industry “best practices” for out-of-network billing.
  • Protect yourself, and your practice from insurance-company driven particular investigation unit (SIU) audits that can result in massive fines or possible jail time for insurance fraud.

PHASE 2Claims Appeal

Once strict compliance is implemented, appeals processes can be handled more aggressively, and higher collections will result.

  • Know your appeal rights and appeal tactically.
  • Exercise efficient and effective appeals to the relevant claims administrator (Aetna, UHC, BCBS, etc.) and ERISA plan sponsors.
  • AVYM can assist NJDPA members on a discounted basis with the following:
    • Learning basic claims appeal procedures.
    • Interpreting EOBs/ERA 835s and recognizing denial types.
    • Challenging and potentially overturning overpayment refund demands and offsets.
    • Challenging and possibly Reversing fake “PPO” or “Negotiated Discount” denials.
    • Preparing for and responding to audits and SIU reviews.

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PHASE 3Claims Litigation

When progress stops on a particular claim, this program will engage one of the country’s leading ERISA experts (AVYM) and one of our legal partners to get your unpaid or low-paid claim adjudicated.

  • Once the administrative appeals process is thoroughly exhausted, the provider and/or patient can sue for benefits due and owing to a patient or provider holding a valid assignment of benefits with the patient.
  • NJDPA members will enjoy the added interests of having a streamlined and cost-effective process, which is specifically designed to put individual members in the best possible position when facing the decision to prosecute.
  • Each payment dispute may be different depending on the factual disposition of the case at the administrative level.
  • Our legal partners have developed strong litigation experience in leveraging various state and federal laws such as ERISA to arm out-of-network providers with viable legal claims designed to place real pressure on payors to pay what is reasonably owed to providers for services rendered.
  • Going even further, to the extent that a given NJDPA member wishes to become a participating provider but has been stonewalled in obtaining access to a given provider network or contract, our legal partners have assisted a multitude of providers in obtaining network access through a legal means.


View the entire Master Class Series.

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