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recoupment request for Out of Network

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EZlabor:
Hello,

 Blue shield of CA and Blue Cross of TX appear to constantly pay OON claims and then request a recoupment for "overpayment" almost a year later. What, if anything, can be done to stop this. It seems they randomly pick claims. The reason is they overpaid, oops, sorry and we want that money back now. I tried looking up the rules for CA providers? and I am not clear on providers rights to contest this constant harassment.
Does anyone have experience with this issue? Or know the provider rights with this issue?

Michele:
We often receive recoupment requests for providers (in Central NY area) a year or more later.  Very frustrating as it is always too late to go after another insurance (if that is the issue) or the patient.  I know you can legally bill the patient still (if the issue was not something that was the provider's fault) but the chances of collecting old debt are so much lower.  Unfortunately I do not know of any way to stop this.  Most times they say they performed an internal audit.  :(

PMRNC:
If any of these recoupment requests are on ERISA group health plans, there most certainly is a remedy. With ERISA a carrier (regardless of the reason for requesting recoupment) MUST recoup from the patient NOT the provider. Again, if it's ERISA, it is a patient's claim, not the providers claim.

Most billers still don't understand that almost 90% of the claims they file are ERISA!

EZlabor:
Thank you both so very much. The Erisa question is one I posed to "specialty attorneys" and they told me it didn't matter if it was related to an audit ( which, you are correct, what they state ). I thought that sounded like they might not know the answer since it was lacking in detail, but how could I say otherwise. Is there a link or somewhere I can find this info? Maybe a reliable site with ERISA info for providers? Again, thank you SO much

PMRNC:

--- Quote ---Thank you both so very much. The Erisa question is one I posed to "specialty attorneys" and they told me it didn't matter if it was related to an audit ( which, you are correct, what they state ). I thought that sounded like they might not know the answer since it was lacking in detail, but how could I say otherwise. Is there a link or somewhere I can find this info? Maybe a reliable site with ERISA info for providers? Again, thank you SO much

--- End quote ---

If again, these are "group health plans" and not church or govt/state plans, they are indeed protected under ERISA which is a federal law. With ERISA those claims belong to the patient, they do not belong to the provider at all. Basically you send them a letter and reference 29 CFR 2560-503-1  Do a CC to the policy holder because they can bring it to their employer for possible
federal review by the Department of Labor and EBSA.  I would reccomend getting the ERISA book from Don Self, it is excellent and NO medical biller should be without it. It's on his website at www.donself.com    Since I learned ERISA from him years ago I've never had to have any of my clients send ONE red dime on a recoupment for ANY reason! If they took the money from additional claims, ERISA worked to get that money back as well (using different type of appeal)  The actual reference to that one law 29 CFR 2560-503-1.. .MEMORIZE it. When I did my first few claims I was including verbiage from that law directly and what I found was I didn't have to. You can even look up cases and reference those with the parties and date of ruling only and it will work. Now Don's book will suggest sending the letter to the CEO of the carrier but I've so far not had to do that one time. I send it as an appeal to the carrier and I make sure it's sent certified and I reference the time they have to respond (just like they do)   YES you may get angry call from patient, but if you find out that the carrier has not notified the patient of this money being due, let them know they can take this to their employer and ERISA can be used to litigate this because the patient has not been informed.

MAKE sure these plans are not govt payer plans (Medicare, Medicaid, Tricare) or state/federal plans or any type of church plan..then you have ERISA.   ERISA trumps state law so when you KNOW it's ERISA, state law goes out the window. Don't even bother.

On Don's website he also has some webinars that are extremely informative.  The book has sample appeal letters to use as well. :)

Once I learned ERISA I dug my heels in because I have challenged my own health policy many many times and WON..even when I was told something was covered but they later denied even referencing where it was stated that it wasn't covered based souly on them telling me it was! :)   I learned ERISA and it's been a big revenue boost to my clients. I also run PMRNC where we have two medical billing certifications and I'm currently getting ready to put out another JUST for ERISA. When a medical biller knows and utilizes ERiSA you become very valuable to your client or employer.

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