ASMAC Webinar - Free for Members!


The Use of Prepayment Review by Managed Care Payors

Date: November 15, 2023, 1:00 pm - 2:00 pm EST
Presenters: Greg Pepe, JD, and Sarah Smeriglio, JD
Recording and Handouts

 Webinar Objectives: Payors are increasingly turning to a process known as PrePayment review (“PPR”) when dealing with physician requests for reimbursement.  S most know, a typical reimbursement request is submitted electronically, is sorted by a computer program that checks for patient eligibility, for services availability under a particular plan, and for reimbursement rate based on provider contract rates.  Payors have started to NOT pay providers for a host of reasons and placing the provider on a program of PPR.  Essentially, the typical PPR program requires that a provider remit underlying medical charts and documentation in paper form justifying the service provided. Those paper documents are then placed in a queue for personal review (allegedly) by a human reviewer before being approved for payment or disapproved for a host of reasons.  Needless to say, this PPR process typically takes many weeks and deprives physicians of cash flow to their practices.  This webinar will discuss some of the tactics being employed by payors, the remedies available to physicians and the effect the PPR practice is having on a physician’s economy.

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  About the Speakers

 Greg Pepe, Founding Principal, Neubert Pepe & Monteith

Gregory J. Pepe heads the Healthcare Law, Alternative Dispute Resolution & Mediation and Corporate & Business Transactions practice areas. His experience in the healthcare market, its accompanying regulatory constructs and related business matters, spans decades. Greg provides his clients the understanding necessary to navigate the changing healthcare landscape.

Healthcare issues that Greg often addresses include how providers can successfully negotiate new market ventures and grow their business strategically while operating within policies and legal regulations. Greg has extensive experience in addressing the myriad of business issues facing healthcare providers. He skillfully provides counsel and solutions for his entrepreneurial clients.

The business issues that hospitals, doctors, lab companies, and other healthcare providers face are extremely complex. Greg works with clients to establish business relationships such as partnership agreements, corporation agreements, noncompetition agreements, compensation arrangements, and provider contracts. The agreements and contracts are crafted to provide the legal structure for the entity to operate effectively. To that end they are constructed with the objective of avoiding future disputes.

Sarah N. Smeriglio, Associate, Neubert Pepe & Monteith

Sarah N. Smeriglio is a member of the firm’s Healthcare Law and Professional Malpractice & Insurance Defense practice groups. While in law school, she joined the firm as a legal extern assisting in the firm’s healthcare practice.

In 2020, Sarah graduated from Quinnipiac University in the three + three law program and received her Bachelor’s Degree in Health Sciences, magna cum laude. Upon entering Law School, Sarah received an International Policy Award Scholarship based in part on her undergraduate studies in the Mandarin Chinese language. She earned her Juris Doctorate, cum laude, from Quinnipiac University School of Law.

Sarah assists in the representation of health care providers and their practices in a variety of matters including the sale and purchase of physician practices, guidance on Anti-kickback, STARK law, HIPAA, the corporate practice of medicine, contract disputes, and Medicaid and Medicare laws. Sarah has experience drafting motions and qui tam actions, conducting discovery, reviewing contracts, and analyzing and drafting case analysis for insurance companies. In her spare time, she enjoys playing golf and figure skating.