Author Topic: Refunding Carriers  (Read 2966 times)

oneround

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Refunding Carriers
« on: December 30, 2009, 11:41:38 AM »
There have been many comments on what constitutes a provider having to pay back a payer when they request payback of an overpayment.  Each state has different regulations.  Some states have no regulations that prevent a provider from having to pay back a payer.  I received this link from a peer and would like to pass it on to those of you that could use it as a reference tool.

http://www.mtbc.com/legal%20corner/Insurance%20Refund%20Recoupment%20LAWS.pdf
Michael A. Reynolds, CPC, CCP-P, CPMB, OS
Project Manager
Corporate Compliance
Sharp HealthCare

Pay_My_Claims

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Re: Refunding Carriers
« Reply #1 on: December 30, 2009, 01:18:06 PM »
thanks..

midwifebiller

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Re: Refunding Carriers
« Reply #2 on: January 06, 2010, 07:24:12 PM »
Thank you for sharing!  We get many requests for refunds, and have clients in many states--this will help us know how to respond.

~Kelli
Kelli Sugihara, CPMB
Midwife Billing & Business, LLC
www.midwifebilling.com

midwifebiller

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Re: Refunding Carriers
« Reply #3 on: January 07, 2010, 08:27:21 AM »
Michael,
Do you have anything to help dispute these refund requests?  I bill for out-of-network providers and have been told that since there is no contract, we are not obligated to refund $$ based on contractual amounts or eligible services, only if there has been a duplicate payment.  After verifying benefits and the midwife receiving reimbursement for her services, it is very annoying to receive a refund request 11.9 months later, saying they made a mistake and need the $$ back.  Any legal information you can share would be greatly appreciated!

Thank you,
~Kelli
Kelli Sugihara, CPMB
Midwife Billing & Business, LLC
www.midwifebilling.com

oneround

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Re: Refunding Carriers
« Reply #4 on: January 07, 2010, 10:51:59 AM »
I have many dispute letters and I'm sure the rest of the network here may have others that may help.  My experience in dealing with the escheatment process is that if the state has no statue and there is no verbaige written into your contracts then a carrier can request at any given time.  Now if there is a state statue the the payer has to obide.  I.E, here in California we have the City of Hope clause which states if the provider did everything in good faith and the payer made the error then they have 1 year to recoup if after a year they do not then they lose out.  I do have a City of Hope letter that we send to the payer telling them sorry Charlie and would be willing to send to you all you have to do is reword it and cite the statue that pertains to the state of the payer all I need is your email and I'd be more then willing to send it to you and anyone else.  Many of the carriers no nothing about state statues.
« Last Edit: January 07, 2010, 11:54:51 AM by oneround »
Michael A. Reynolds, CPC, CCP-P, CPMB, OS
Project Manager
Corporate Compliance
Sharp HealthCare

midwifebiller

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Re: Refunding Carriers
« Reply #5 on: January 07, 2010, 01:45:16 PM »
Michael
You're referring to the court case of City of Hope Medical Center v. Superior Court of Los Angeles County (1992). We have referred to this case in our letters to BC and BS of CA (since they seem to want money back frequently), but have not had good results.  I would like to see your refusal letter, if you don't mind, to see what we might be missing.

Thank you!
~Kelli
kelli.sugihara@midwifebilling.com
Kelli Sugihara, CPMB
Midwife Billing & Business, LLC
www.midwifebilling.com

oneround

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Re: Refunding Carriers
« Reply #6 on: January 07, 2010, 02:07:57 PM »
We also have the same issue with BC BS.  because everything is done EFT they constantly retract and we don't catch it until it show  on our AR we have to appeal.  With our HMO and PPO plans for BC BS it is written in our contract that they cannot take payment back if they pd in error after 365 days.  With ERISA plans it's the city of hope clause.  I cannot show our contract verbaige but I do have some legal references for you.  www.ahcinc.com is a good source.  Lawrence Reid, ESQ.  is a great Attorney that deals with refund laws.  He wrote an article titled 'Dealing with refund demands.  Problem with this carrier is that even with the clause and our contract they still try to retract.  We have to spend the extra manpower to appeal but we usually win.
« Last Edit: January 07, 2010, 06:37:35 PM by oneround »
Michael A. Reynolds, CPC, CCP-P, CPMB, OS
Project Manager
Corporate Compliance
Sharp HealthCare

Pay_My_Claims

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Re: Refunding Carriers
« Reply #7 on: January 07, 2010, 07:02:57 PM »
They do what they do because they can..........

midwifebiller

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Re: Refunding Carriers
« Reply #8 on: January 07, 2010, 10:54:45 PM »
Thank you again, Michael.  It's somewhat comforting to know that other providers have similar problems with the carriers.  The weblink you shared has quite a bit of helpful information!

~Kelli
Kelli Sugihara, CPMB
Midwife Billing & Business, LLC
www.midwifebilling.com

Anand

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Re: Refunding Carriers
« Reply #9 on: January 08, 2010, 06:23:57 AM »
There have been many comments on what constitutes a provider having to pay back a payer when they request payback of an overpayment.  Each state has different regulations.  Some states have no regulations that prevent a provider from having to pay back a payer.  I received this link from a peer and would like to pass it on to those of you that could use it as a reference tool.

http://www.mtbc.com/legal%20corner/Insurance%20Refund%20Recoupment%20LAWS.pdf

Hello - any ideas when this rule was applied? Is thier any changes in the rule for 2010? Thanks