Reimbursement
Disputes, settlements, and payor adjudication for government and commercial claims.
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Physicians & Medical Groups
Counsel for physicians and medical groups on underpayments, downcoding, audits, credentialing, and payor contracts.
A physician group gets paid visit by visit, then lives with the recoupment, the downcode, and the contract term nobody read until the remittance changed. Rivet Health Law advises physicians and medical groups on how those claims are built, reviewed, and disputed.
Reviewed by Joseph Rivet · September 30, 2026
The Challenge
Where physician revenue usually breaks
The expensive problems are often quiet. A commercial plan reduces an established-patient visit by one level. A modifier is stripped. A new clinician bills for weeks before credentialing is complete. None of those look like a lawsuit. They look like a thinner deposit.
Evaluation and management coding and add-on codes such as G2211
Learn moreCommercial downcoding and silent fee-schedule changes
Learn moreMedicare and Medicaid audit response
Learn moreCredentialing delays that stall payment
Learn moreNo Surprises Act questions for office and facility claims
Learn moreAgreements that assign professional fees
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Who We Help
Who this work is for
Joseph Rivet spent more than 20 years in coding, billing, compliance, and reimbursement before practicing law, including work inside payer organizations. Group matters are read the way a reviewer reads them: the note, the code, the policy, then the letter.
- Independent and multispecialty medical groups
- Office-based and hospital-based physician practices
- Groups adding a site, a service, or a mid-level clinician
- Practices that just received a probe, a downcode, or a takeback
Our Process
First steps you can take today
These steps organize the file. They are not a substitute for counsel.
- 1
Pull ten recent remittances that paid less than expected and write down the reason code.
- 2
Match each remittance to the note and the code that went out.
- 3
Check whether a new clinician’s claims are pending credentialing rather than denied on the merits.
- 4
Note the appeal deadline on the oldest remittance before you build a larger sample.
The useful question is whether the chart, the code, and the payor’s written rule agree. If they do not, the group needs the appeal path and the deadline, not a general complaint about reimbursement.
What to settle before the next contract year
Fee schedules, downcoding policies, timely-filing limits, and who may offset unrelated claims should be in the contract, not inferred from a portal. Groups that sign a template and then discover the policy on a remittance are negotiating from behind.
Employment and professional-services agreements belong in the same conversation. If the group bills the professional fee, the contract should say who owns the receivables, who answers an audit, and what happens to tail coverage when someone leaves.
Common questions
- Can a commercial plan downcode an office visit without a record request?
- Some plans do, under a written reimbursement policy. Whether that reduction is allowed depends on the contract, the policy, and the note. A pattern of one-level reductions is a reimbursement dispute, not something the group has to accept as editing.
- Does the No Surprises Act apply to a physician office?
- It depends on the service and the setting. Emergency services, certain nonemergency services at in-network facilities, and air ambulance have specific rules. A routine office visit billed under a direct contract usually follows that contract. The setting and the plan type decide which rule applies.
- When should a group call counsel instead of the billing company?
- Call when the issue is a legal deadline, a recoupment, a contract interpretation, or a government audit. The billing company can reprint a claim. It should not be the one deciding what to concede in an audit response.
800 E. Ellis Road, Ste 515, Norton Shores, MI 49441
(231) 799-4870
info@rivethealthlaw.com
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Bring these
6 itemsDocuments that make a group review faster
A short file beats a full chart room. Start with the items that show how the claim was paid and what the plan said it would do.
Check items off as you collect them. Your progress is saved on this device.
This sheet is a gather list for your own file. It is not legal advice.
Related Services
Practice areas that come up here
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Coding guidelines, modifiers, rebilling, and practical CPT, HCPCS, and ICD-10 application.
Learn MorePayor Audits & Appeals
Audit response and appeals from the first letter through resolution.
Learn MorePhysician & Mid-level Provider Agreements
Review and negotiation of provider employment agreements before they are signed.
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Other industries
This page is general information about how this setting is paid and reviewed. It is not legal advice and does not create an attorney-client relationship.