Author Topic: copay refunds  (Read 2463 times)

dekenn

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copay refunds
« on: June 08, 2015, 11:58:06 AM »
I'm looking for some guidance in getting copays refunded.
I am a biller for a podiatry practice and recently my grandmother (who does not live nearby) had an eob where something was rejected (for lack of modifier). She has been seeing this particular podiatrist regularly for 4 years. When looking at the eob, I noticed that the insurance company did not apply a copay to the visit, there was no patient responsibility. Curious, because I know she complains about the copay... how they ask for it even before she sits down, I asked to see her other copays.

Anyway, from the records I have, the office has been charging and accepting a copay at every visit. The insurance company does not ever apply a copay charge. This has been going on for four years. I called the office on behalf of my grandmother to inquire about a refund. The person I spoke to seemed surprised that this was happening and she would have to check each and every eob, and since this has been going on for while, it would take her a LONG time. I asked for a time frame, and was told, "Oh, a VERY long time"... It's been six weeks, and they will not return my phone calls, nor has my grandmother gotten a refund check.  I know what MY procedures would have been (of course, it wouldn't have been going on for four years), and the patient would have gotten a refund within a week, with a note of apology.

In addition, my grandmother informed me that three months ago, she was told that "because Medicare is cutting back on what they reimburse us, we'll have to charge you $60 per visit from now on". I was LIVID!!! I feel this office is committing fraud on a regular basis and doesn't seem to care...

What's the most effective way to not get my grandmother's money back, but make sure their office is looked into for fraud purposes?

Linda, I know you're very well versed in fraud and reporting fraud, I was hoping you could help me out with some guidance. Thanks so much in advance

Merry

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Re: copay refunds
« Reply #1 on: June 08, 2015, 12:07:55 PM »
Not Linda but may I ask.. does your grandmother have a Medicare Advantage plan or does she have Original Medicare with or without a Medigap plan. In order to help you we (Linda) will need more info.

PMRNC

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Re: copay refunds
« Reply #2 on: June 08, 2015, 12:23:04 PM »
I would ask same thing. Medicare or Medicare managed care/advantage?

Is this the same podiatrist you work for?

If possible can you contact carrier in writing and make formal request for all EOB's related to this provider? under FOI (freedom of information) you can .. need to know more about the insurance plan first though, as ERISA claims are with Dept of Labor and non ERISA (church, govt, state) are with state dept of insurance and you might need one or the other to help you with this request.
Linda Walker
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dekenn

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Re: copay refunds
« Reply #3 on: June 08, 2015, 12:28:58 PM »
She has a Medicare Advantage plan, and does have a copay if there is an office visit charge. But, as I'm sure you all know, if there is no e&m, only the routine foot care charge, some insurance plans don't apply the copay, but pays the physician 100% of the allowable for the services, clearly showing on the eob $0 patient responsibility. I know it depends on the plan, I have ones that apply a copay no matter what, and others where there is no copay unless there is an e&m charge. I checked all the eobs my grandmother had (2014) and there was $0 patient responsibility on every one.

Now, I know with a new plan, or new patient, you don't always know which way it's going to go, so we do collect the copay. But as soon as I see that the plan is not applying it, I instruct the front desk to not collect the copay unless the doctor checks off an office visit. I don't let it go on for years.. and I DON'T tell the patients they have to pay more because Medicare is cutting back.... I think that is what gets me the most angry. Taking advantage of seniors who are not savvy about medical insurance....

dekenn

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Re: copay refunds
« Reply #4 on: June 08, 2015, 12:32:56 PM »
And no, this is not the same podiatrist I work for! It would never have happened!  ;)
My mom is close by and can facilitate any requests to the insurance company.
At least for 2014, this is a black and white issue, I have the receipts of copays paid by my grandmother, and the eobs showing zero responsibility.

PMRNC

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Re: copay refunds
« Reply #5 on: June 08, 2015, 01:10:38 PM »
Definitely sounds WRONG to me. Start by making formal request for all EOB's for that provider. Put your request in writing and send it certified mail.
Do same with the podiatrist. Request an itemized statement (or ask for patient audit record) for ALL patient history/visits. AT very least you will put them on notice.

Your refund is going to come from the doctor. You already know that..but the key to doing this is to alert the insurance carrier AND the doctor and let them know you are on to them. You could be pleasantly surprised to find a check in the mail shortly... <g>

DO both these requests CERTIFIED RETURN RECEIPT .. :) 
Linda Walker
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www.billerswebsite.com

dekenn

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Re: copay refunds
« Reply #6 on: June 08, 2015, 01:43:40 PM »
Thanks, Linda!
I actually spoke with the billing person at the doctor's office.... she knows I'm on to her, and honestly, I did expect a prompt response. I've already told her, via voice message (she won't return phone calls) that my next step is to contact the fraud department.... still no response...I'm thinking maybe the doctor doesn't know what's going on???

Will send out the letters as you suggested.... thanks again!

PMRNC

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Re: copay refunds
« Reply #7 on: June 08, 2015, 02:15:16 PM »
Always smart to ask them for a patient "AUDIT of ACCOUNTS" The word "audit" should make them stand up straight. :)
Linda Walker
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RichardP

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Re: copay refunds
« Reply #8 on: June 08, 2015, 06:53:16 PM »
... formal request for all EOB's for that provider.

By all EOB's I assume you mean all EOB's for the patient in question for that provider?

kristin

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Re: copay refunds
« Reply #9 on: June 08, 2015, 07:11:36 PM »
As the office manager and biller for a podiatry office, what this office is doing really ticks me off.  >:(

I mean, c'mon...you run an A/R report every month, and you can clearly see if there has been an overpayment on an account, and you figure out why, and who needs to be refunded, either patient or insurance. This isn't rocket science. So they had to know month after month that there was a credit on your grandmother's account, and they just ignored it, or worse, did an adjustment in her account to make the credit not show up.

I also think it is a load of BS that it would take a LONG time to research this...EOB's are financial records, and should be kept on file for seven years, at the minimum. I don't care in what format, be it paper, or scanned onto disc, or whatever. I could find EOB's on four years worth of visits for one patient in less than an hour in my office. So they are stonewalling you with that lame excuse.

Finally, I can't tell you how many patients we get in a year with Medicare or MA plans, that clearly meet the requirements for having their nails debrided, but that have been seeing various podiatrists who have made them pay $50-60 cash to have the service done. Because the office/doctor told them "this isn't a covered service with Medicare". Which means either the office/doctor clearly do not understand what is considered a covered service with Medicare, or they do, and they just flat-out lie to the patient to make them pay more with their cash payment then they would receive from Medicare.

So what I would do in terms of what they told your grandmother about charging her is call Medicare and the OIG. And I most definitely would get her another podiatrist, and vet the office beforehand for her.