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Refunding Carriers

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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.


Thank you for sharing!  We get many requests for refunds, and have clients in many states--this will help us know how to respond.


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,

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.


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