Medicare and Private Insurance Reimbursement and Audits

Sansweet, Dearden and Burke, Ltd. (SDB) advises clients regarding reimbursement and payment issues with Medicare and private insurance. Our firm has extensive experience with audits, chart reviews and requests for overpayment. In addition, we research and respond to questions on proper billing and help clients take a proactive approach to payment issues. We also assist clients with reviewing and negotiating agreements with billing companies in an attempt to make sure that such agreements define the services to be provided by billing companies and to address the remedies that are available when the billing company fails to satisfy its duties in this regard.


SDB has represented many clients in responding to Medicare and private insurance requests for reimbursement of an overpayment, as well as appealing overpayment claims. In addition, our firm helps clients analyze potential claims for overpayment that they have discovered internally. Often, these issues come to light as part of payment review audits conducted in connection with a health care provider’s internal compliance plan. SDB often engages a coding consultant to work as part of a team with SDB in reviewing our client’s billing compliance processes. These issues ultimately must be reviewed in light of applicable federal and state law, such as the Medicare statute requiring repayment of discovered overpayments. Where private insurance is involved, contracts with such third party payors and their policies and procedures are also relevant to this analysis. We have significant experience in handling overpayment and can assist our clients in all aspects of the process of dealing with overpayments, whether such issues are raised by Medicare or a private insurer or as the result of an internal review or audit.

Potential False Claims

Our attorneys also address potential false claims issues (please see Anti-Kickbacks) and assist clients with self-disclosing billing irregularities where warranted. The scope and nature of how such issues are handled varies depending upon whether the issue involves Medicare or private insurance and the nature of the issue that is brought to the attention of our clients by third parties or discovered by our clients internally.