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Insurance co./collection co. requested reimbursement for out of network facility

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  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.

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.

Is the plan an ERISA Plan? IF so there's a great chance of not having to pay back a dime of that money.

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!

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.



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