Overbilling Advocacy Review

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Physician Assistant

An employer guide to Reclaim's overbilling advocacy program, from detection to appeals

detect errors

Detection

Review

Issue(s) Identified

Claims ingestion

Claims processing

Advocacy

Reclaim:

• Ingests post-adjudication claims data
• Compiles events (ER visits, admissions, procedures, etc.)
• Applies coding and utilization logic
• Calculates over-billing triggers

Reclaim

The carrier/TPA:

• Adjudicates the claim
• Applies deductible and coinsurance
• Issues an Explanation of Benefits (EOB)

This is the starting point for Reclaim’s review.

• Billing errors
• Coding inconsistencies
• Upcoding
• Duplicate services

• Modifier misuse
• Medical necessity discrepancies
• Utilization mismatches

Recovery

Appeals

An employer guide to Reclaim's overbilling advocacy program, from detection to appeals

review details

Detection

Review

Develop Strategy

Advocate Review

Member Notification

“We identified a billing issue and are reviewing it on your behalf, hold off on paying for now. An advocate is working to review the charges.” No action required from member.

Advocacy

Reclaim advocate

• Reviews the flagged codes
• Confirms the issue
• Confirms eHIPAA on file and/or member did not opt-out

Reclaim advocate determines whether it is a carrier adjudication issue or a provider coding issue

Recovery

Appeals

An employer guide to Reclaim's overbilling advocacy program, from detection to appeals

advocate for member

Detection

Review

Provider Outreach

Carrier Outreach

Member Outreach

Advocacy

Reclaim Advocate

• Calls the carrier
• Requests claim reprocessing
• Cites CPT/NCCI rules if applicable
• Documents reference numbers
• Tracks reprocessing timeline

Reclaim Advocate

• Contacts the provider billing department and requests to freeze bill
• Requests corrected claim submission
• Provides coding explanation
• Tracks correction timeline

If required Reclaim's Advocate may reach out to the member for additional information

Recovery

Appeals

An employer guide to Reclaim's overbilling advocacy program, from detection to appeals

RECOVER funds

Detection

Review

Refunds

If Carrier denies error

If Carrier/Provider confirm error

Advocacy

If member already paid:

• We confirm refund eligibility
• We coordinate with provider or carrier
• We confirm where refund should be sent
• Our Advocate tracks until refund is received.

• Claim is reprocessed
• A new EOB is issued
• Provider re-bills correctly
• Member patient responsibility is reduced

Reclaim will proceed with the appeals process.

Recovery

Appeals

An employer guide to Reclaim's overbilling advocacy program, from detection to appeals

Appeals process (IF NEEDED)

Detection

Review

Second level appeal

State level appeal

Formal appeal

Advocacy

If internal appeals are exhausted and liability remains material, Reclaim Advocate may:

• File an external review
• Escalate to state insurance department
• Submit independent review request

Reclaim Advocate

• Gathers documentation
• Drafts formal appeal letter
• Submit through carrier channel
• Logs timeline and reference number
• Monitors response window (30 days)

If first appeal denied, Reclaim Advocate escalates:

• Supervisor review
• Medical director review
• Formal second level appeal

Recovery

Appeals

Reclaim advocacy is designed to do the heavy lifting.

Transparency and engagement, without the hassle. Reclaim Advocate will reach out to members:

Via In-app notifications to provide updates on issue detection, recovery and appeals

Directly if information is missing for the claims or appeals

Directly if needed to manage refund logistics

confidential & proprietary

Overbilling demo