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Patient and Insurance credit balances

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Michele:
Good point!

Pay_My_Claims:
Thanks,
I agree with the posters comment on the legal issues, but we simply have no control over it. I had one provider that wouldn't allow me to tell the client they had a credit, but I told them I was legally obligated otherwise that would be double billing. She frowned and let me do my job.

PMRNC:
I agree with you on the issues with the credits to the patient.. however..
The laws regarding "fraud/abuse" are very clear.  If YOU know your provider owes a refund to an insurance carrier, you are then "aware" and just as libel if you do nothing. That is why it's incredibly important to have a compliance plan in the office or if you are a third party billing company. Your compliance plan is what you would refer to in order to follow procedure.  It's no different if a doctor insists on up-coding and the biller KNOWS it's up-coding, they are just as legally libel.  The same would even be equally true if it were an office manager employed by a physician. Their employment does not release them of the legal ramifications of the job functions/law. While we can't FORCE the provider to write the check, proper procedures to notify the patient and/or the insurance company to the credit is the right and legal thing to do, then they in turn will make the request/demand for payment return, if they don't, you are off the hook.
of course...DOCUMENT and CYA!

Pay_My_Claims:

--- Quote from: PMRNC on March 15, 2009, 11:53:49 PM ---I agree with you on the issues with the credits to the patient.. however..
The laws regarding "fraud/abuse" are very clear.  If YOU know your provider owes a refund to an insurance carrier, you are then "aware" and just as libel if you do nothing. That is why it's incredibly important to have a compliance plan in the office or if you are a third party billing company. Your compliance plan is what you would refer to in order to follow procedure.  It's no different if a doctor insists on up-coding and the biller KNOWS it's up-coding, they are just as legally libel.  The same would even be equally true if it were an office manager employed by a physician. Their employment does not release them of the legal ramifications of the job functions/law. While we can't FORCE the provider to write the check, proper procedures to notify the patient and/or the insurance company to the credit is the right and legal thing to do, then they in turn will make the request/demand for payment return, if they don't, you are off the hook.
of course...DOCUMENT and CYA!

--- End quote ---

You may want to go back and re-read all the replies. Nobody stated to NOT tell the provider, however it was stated that we have no control over the refunds. We did state that once you determine that it is a true credit either for the patient or the insurance company then you notify the provider, however you can not make them give the refund!!!  So I am missing something in this reply

PMRNC:
I wasn't necessarily picking on anyone at all, yes you tell the provider, but if the provider owes the insurance company or the patient and you know about it your are legally responsible also to notify the carrier and/or the patient.
I was just clearing up the legal "responsibility" process.

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