Author Topic: Insurance co./collection co. requested reimbursement for out of network facility  (Read 3763 times)

Game_Of_Billing

  • Newbie
  • *
  • Posts: 6
Hello,

  I'm pretty new to the billing world. I have had years experience in the collection industry, until recently I started working with a medical office out of Los Angeles CA assisting them with accounts receivables and their in-house collection accounts. My boss asked me to work on an insurance co demand for reimbursement on claim with Health Net. The claims is over 40k. We initially filed a facility claim in Oct. 2012, mind you our facility is out of network with all insurance co's. About a month after filing the claim the insurance company paid out the full amount of our claim. Now 3 years later I get a call from a Collection agency demanding over 40k in reimbursement given HN does not pay a dime for our out of network facility. They claim we received 3 notices, first notice a month after payment and the other two every other month.

1. our office never received request from insurance co for reimbursement
2. no calls were made regarding this claim only a collection call 3 years later
3. we never misrepresented our facility as in - network


I found court rulings in California against blue cross for similar demand for repayment on paid claims the insurance co paid in error by no fault of the provider. I rejected their request for payment with a letter I found from a law firm online pointing out the ruling in Ca.
They are threatening to damage the Facility co's credit score and [proceed with collections.


Does anyone have any advise with this matter... sorry for the grammar I was typing this up in a rush as my office was closing fr the week.


kristin

  • Sr. Member
  • ****
  • Posts: 492
If an insurance company ever came after my doctor for $40,000 worth of previously paid claim(s), that I knew were billed cleanly, and paid cleanly, I would call a healthcare attorney and have them fight the recoupment demand for our practice. That is WAY too much money for me to try and handle it on my own.

The problem I see with your situation, in my opinion only, is that while the claim(s) may have been billed cleanly, it looks like they should have never been paid at that amount, and you would think someone in the practice would have realized that right away back in 2012, and investigated it before cashing the check.

I would hire an attorney, that is my advice.

PMRNC

  • Hero Member
  • *****
  • Posts: 4237
    • One Stop Resources & Networking for Medical Billers
Is the plan an ERISA Plan? IF so there's a great chance of not having to pay back a dime of that money.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Game_Of_Billing

  • Newbie
  • *
  • Posts: 6
Thanks for all the advice... I went ahead and denied their claim pointing out the court ruling against blue cross in the case of city of hope hospital vs. blue cross. Funny thing was that today we get another demand for reimbursement from Blue Cross now! They paid our out of network facility over 40k and are requesting 20k back due to price change the patients plan had. We were informed by the patient who received a collections notice a year later! The surgery was Nov. 2011, the patient received notice November 2012 and we were not informed of this until December 2012 thatís over a year after payment! These insurance companies are ridiculous! Looks like I need to send them another denial letter!

Game_Of_Billing

  • Newbie
  • *
  • Posts: 6
UPDATE: just got notice that the insurance company has placed the patient in collections for the 22k they claim was overpaid. They are pursuing the patient because the check was made out to the patient then forwarded to us for payment. I plan to use the city of hope supreme court ruling against them but I need them to back off from our patient.

ANY ADVISE?
« Last Edit: July 10, 2015, 07:01:03 PM by Game_Of_Billing »

PMRNC

  • Hero Member
  • *****
  • Posts: 4237
    • One Stop Resources & Networking for Medical Billers
Quote
I plan to use the city of hope supreme court ruling against them but I need them to back off from our patient.

This is why I asked you if this was ERISA plan. With any ERISA plan, the claim is not yours, it's the patient's claim. Unless you had authorization to act on their behalf there isn't much you can do now after the fact. You have several steps and how you proceed depends on the plan. ERISA vs. Non ERISA.   You need an authorization to act on behalf of the patient. You need to check timely filing or the appeals, check recoupment time periods for your state, once that's done you move to the next step which is the appeal. You can't just appeal the refund request, you also have to appeal the actual claim. You have to also see if the patient did anything to appeal this WITHIN the time period given. You will need all correspondence from the insurance company to the patient since you indicated payment(s) sent to the patient not your office.   Your first hurdle is the timely filing. Again as a reminder if this is an ERISA policy it is the patient's claim.

One more thing...you mention the patient was never notified until a year after, that could be within the allowed period and it's also possible the patient was "mistaken"... Before you go all crazy over this, I suggest taking a look at the original claim and the patient's SBP and first seeing if the claim WAS processed incorrectly. I'm not saying that even if the claim was processed incorrectly you still have to pay the money.. as it is right now the patient owes the money but they can decide later to pursue from you.. Remember that you mentioned you were out of network, so let's say the patient was responsible for paying the balance anyway? You have to understand that if this truly was out of network benefit, patient is the claimant, not your office, you may end up with a lot of unnecessary paperwork for a claim that you have technically been paid on. I understand wanting to help the patient, but you have to understand the steps to do so.

Don Self has a great book available to help you with ERISA appeals. www.donself.com    PMRNC also has an area for ERISA in our members only area. www.billerswebsite.com

« Last Edit: July 08, 2015, 01:01:24 PM by PMRNC »
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Game_Of_Billing

  • Newbie
  • *
  • Posts: 6
how do I find out if the plan falls under this ERISA set of rules? I was given this old claim by my manager and asked to follow up with the insurance co to have them cease collections on the patient. All of this mess started with Blue Cross claiming price changes for this patient that they claim was applicable at the time of service 6/9/2011. Back in November of 2012 we were informed by the patient BCBS was threatening collections on the patient so we went ahead and contacted BCBS  requesting that they provide our office with manual listing for 2011-2012. We made many requests for this info. All they had provided was a letter of explanation regarding adjustments made. Last we have heard of this was back in May 2013.

Now the collection agency is knocking on the patient's door asking for $22k!
« Last Edit: July 13, 2015, 11:33:29 AM by Game_Of_Billing »

PMRNC

  • Hero Member
  • *****
  • Posts: 4237
    • One Stop Resources & Networking for Medical Billers
ERISA plans are employer based health plans non govt or church. With ERISA. If your patient's plan is a group plan not given by state/fed govt or a church, most likely it's ERISA. If it is ERISA, you would need to contact the patient for a copy of their summary of benefits as well as get them to sign an authorization for you to act on their behalf.. since they are going after the patient, there's not much you can do since you didn't have a contract with BCBS (I am deducing that from your prior posts). Bottom line at this particular point is the patient owes the money. You can file an appeal with BCBS on behalf of the patient with appropriate documentation, however if the patient's timely appeal limit is up, there may be nothing YOU can do. The patient can however then proceed with a formal appeal to their human resource dept, union or legal dept. You need two important things here to even move forward.

1) Summary of plan benefits - this will give you all the info on contact, timely filing limits, appeal filing limits and procedures for appeal under ERISA.
2) A copy of ALL EOB's and correspondence the patient or your office received (you may not have these with BCBS even with an AOB if you were non par). You will need to rely on the patient's correspondence and EOB's. Since they are asking for money BACK.. I'm assuming the claim was paid by them, in which case you need THAT EOB to examine any appeal rights (time frame, etc).   With ERISA the patient can also persue legal actions if warranted. (this is on them, though you can't do that).


In your situation it's going to matter when the last correspondence on the claim was.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

kristin

  • Sr. Member
  • ****
  • Posts: 492
Linda, I have a question, since I have been following this thread with great interest, (and very thankful I have never had to deal with a situation like this, what a nightmare):

When you say that bottom line at this particular point that the patient owes the money, what is the patient supposed to do, since they turned the money over to the provider, and no longer has it?

PMRNC

  • Hero Member
  • *****
  • Posts: 4237
    • One Stop Resources & Networking for Medical Billers
Quote
When you say that bottom line at this particular point that the patient owes the money, what is the patient supposed to do, since they turned the money over to the provider, and no longer has it?

Well again.. ERISA states this is the patient's claim. I hate to sound like a downer..but it's the patients's responsibility. They had charges with a NON par provider, there is NO contract with the provider and the plan to go with.. this really is a patient appeal.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Game_Of_Billing

  • Newbie
  • *
  • Posts: 6
Quote
When you say that bottom line at this particular point that the patient owes the money, what is the patient supposed to do, since they turned the money over to the provider, and no longer has it?
 

Well again.. ERISA states this is the patient's claim. I hate to sound like a downer..but it's the patients's responsibility. They had charges with a NON par provider, there is NO contract with the provider and the plan to go with.. this really is a patient appeal.

@Kristin- do concider yourself Lucky. Im running into these issues as our facility is a high volume surgical center and unfortunately these insurance companies drop the ball all the time. For the most part we comply when informed timely about a reimbursement provided they send us the necessary documentation to do so. But when they come out the blue demanding payment after years of doing nothing then having some agency attack, this I will not tolerate.

@PMRNC - Wow! I have an uphill battle. We are trying to do what's right for the patient. I have requested any and all documentation, mail/correspondence we have received to be sent to me for review. As soon as I have that and a signed rep/auth. letter I will research what chance if any the patient has to fight this. If the patient is dead in the water I might even suggest to my boss the possibility of negotiating a settlement with the collection agency and or advising the patient to seek legal help.

But now lets take a step back and talk about what first lead me to this Forum and seek help.
The healthnet 40k claim any other advise you can throw my way because this out of network claim HN's collection agency is attacking the facility directly which will hurt the business's credit rating. I had responded with a letter rejecting their claim but they seen to just ignore it.... I used a response from a California firm that points out numerous case laws from different states that favors providers who file claims correctly and are then pursued by Insurance carriers for re-payment. In most all the cases the insurance company is the looser as the provider did nothing to mislead the insurance company and the error fall completely on the insurance provider. I had used a template from a California attorney David Mullens and spoke with the attorney who said we are in a good position to stand our ground but any further advise would be at a price if we decide to hire/have his firm represent us.

Here is the to the template this attorney The law Office Of David D Mullens.

http://www.mullenslawoffice.com/article-justsayno-part1.html

PMRNC

  • Hero Member
  • *****
  • Posts: 4237
    • One Stop Resources & Networking for Medical Billers
Quote
HN's collection agency is attacking the facility directly which will hurt the business's credit rating.

Ok, but I was under the assumption from your original post that the patient was being pursued for collection? How does this affect the facility? I think I'm a bit confused because in another post you mention BC coming to you for reimbursement?

Quote
About a month after filing the claim the insurance company paid out the full amount of our claim. Now 3 years later I get a call from a Collection agency demanding over 40k in reimbursement given HN does not pay a dime for our out of network facility. They claim we received 3 notices, first notice a month after payment and the other two every other month.

Can you clarify:

Claim was out of network, went to BC? BCBS in many states do not have to honor AOB for non contracted providers.
Who was sent the full payment of the claim? Facility or patient?

I think that's why I'm confused.. not sure I understand who paid and who owes.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Game_Of_Billing

  • Newbie
  • *
  • Posts: 6
Quote
HN's collection agency is attacking the facility directly which will hurt the business's credit rating.

Ok, but I was under the assumption from your original post that the patient was being pursued for collection? How does this affect the facility? I think I'm a bit confused because in another post you mention BC coming to you for reimbursement?

Quote
About a month after filing the claim the insurance company paid out the full amount of our claim. Now 3 years later I get a call from a Collection agency demanding over 40k in reimbursement given HN does not pay a dime for our out of network facility. They claim we received 3 notices, first notice a month after payment and the other two every other month.

Can you clarify:

Claim was out of network, went to BC? BCBS in many states do not have to honor AOB for non contracted providers.
Who was sent the full payment of the claim? Facility or patient?

I think that's why I'm confused.. not sure I understand who paid and who owes.


Sorry, I am dealing with two claims;

1.in 2012 healthnet sent our out of network facility 40k payment directly to us and claims they sent 3 notices "that we never received" 2 months after sending the check due to paying out our facility as in network when we were out of network.  The collection agency is pursuing our facility 3 years later... no calls were ever made to our facility. This is the first we heard of this. 

2.blue cross is demanding payment directly from patient for 22k due to overpayment because of a plan price change. From what I have received so far it seems they paid in error at the prior years price  .

** I am dealing with two difrent demands. One from health net demanding 40k payment directly from our facility for paying us as in network when we are out of network. Second is from Blue cross taking a patient to collections for an out of network check sent directly to the patient which was then forwarded to us.
« Last Edit: July 16, 2015, 02:06:14 PM by Game_Of_Billing »