Author Topic: BCBS non-payments and overpayments?  (Read 1477 times)


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BCBS non-payments and overpayments?
« on: February 09, 2020, 08:27:55 PM »
Hi! My employer and I have been contacting our provider rep persistently. She told us to contact the claims department regarding this issue, and one woman who had some empathy for us said that the provider rep should be assisting us with this. She has not even responded to any of our 4 emails and calls. The situation is this:

My employer (a LMFT) has been receiving non-payments as a result of "overpayment." The customer reps from BCBS told us that we have an alarming accounts receivable balance, and that we would continue getting non-payments until that balance cleared. We do not understand this issue, where to turn, or what we can do to start getting paid again!!! There have been no notices, and they have withheld over $80,000. We are looking for help and guidance on this. What would be your next step?

Any help on this would be greatly appreciated!!!


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Re: BCBS non-payments and overpayments?
« Reply #1 on: February 10, 2020, 05:32:02 PM »
Here is a link to how BCBS of Illinois (my BCBS payer) handles refund requests:

You should go to the website for your BCBS payer, and see what information is there for how they handle these requests. I have never heard of any BCBS in any state just taking back the money through offset, without notifying the provider first in some fashion. Obviously having the provider rep help you is the first step, but seeing as how yours is ignoring calls/emails, you need to look at other methods of getting to the bottom of this also.

You should also see if Availity has an Electronic Refund Management tool like we have for BCBS of Illinois, because then if you register for it, you can see all the requests, and dispute them if necessary. It will also send you emails when a new request is added.

Also, it sounds to me like BCBS has identified something in the way the claims were billed/coded that has caused them to go back through everything submitted in the past and make a mass adjustment for over-payment to your provider. I saw this happen with a doctor who was billing a certain type of very expensive injection for awhile, and eventually BCBS figured out that he was an outlier in how he was billing it, and that he incorrectly coded his claims/lacked medical necessity for the injections. They sent him a letter saying he owed BCBS over $200,000, and he won't see payment from them for a long time. I am not saying your provider has done anything illegal, just that BCBS has found some sort of very large irregularity if they want that much money back.


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Re: BCBS non-payments and overpayments?
« Reply #2 on: February 11, 2020, 12:43:43 PM »
Yes. The provider reps are the ones that could help. But in your case it's already been ruled out. Here's what I would do. I will look at samples of the claims against which the payments are adjusted. Meaning, the claims that were earlier paid and the payer considers that as an over payment. You can find those claims using the ICN (Claim number) given on the remittance advise.

With the given fact that your current claims are being processed but not paid, it means that the current claims are good else they would have denied, had you continued to be billing incorrectly.

One other factor that could cause this is the Network participation effective date. Sometimes, providers are confused with credentialing completion dates and network participation dates. Due to this, providers start billing claims from the credentialing completion date whereas there may be a contract that may need to be executed. Any claim paid between credentialing and participation date may be considered as over payment. Please do look for the EOB to see which claim they are taking the money back from and see if there are abnormalities found in such claims. Good luck.

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Re: BCBS non-payments and overpayments?
« Reply #2 on: February 11, 2020, 12:43:43 PM »