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copay refunds

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I'm looking for some guidance in getting copays refunded.
I am a biller for a podiatry practice and recently my grandmother (who does not live nearby) had an eob where something was rejected (for lack of modifier). She has been seeing this particular podiatrist regularly for 4 years. When looking at the eob, I noticed that the insurance company did not apply a copay to the visit, there was no patient responsibility. Curious, because I know she complains about the copay... how they ask for it even before she sits down, I asked to see her other copays.

Anyway, from the records I have, the office has been charging and accepting a copay at every visit. The insurance company does not ever apply a copay charge. This has been going on for four years. I called the office on behalf of my grandmother to inquire about a refund. The person I spoke to seemed surprised that this was happening and she would have to check each and every eob, and since this has been going on for while, it would take her a LONG time. I asked for a time frame, and was told, "Oh, a VERY long time"... It's been six weeks, and they will not return my phone calls, nor has my grandmother gotten a refund check.  I know what MY procedures would have been (of course, it wouldn't have been going on for four years), and the patient would have gotten a refund within a week, with a note of apology.

In addition, my grandmother informed me that three months ago, she was told that "because Medicare is cutting back on what they reimburse us, we'll have to charge you $60 per visit from now on". I was LIVID!!! I feel this office is committing fraud on a regular basis and doesn't seem to care...

What's the most effective way to not get my grandmother's money back, but make sure their office is looked into for fraud purposes?

Linda, I know you're very well versed in fraud and reporting fraud, I was hoping you could help me out with some guidance. Thanks so much in advance

Not Linda but may I ask.. does your grandmother have a Medicare Advantage plan or does she have Original Medicare with or without a Medigap plan. In order to help you we (Linda) will need more info.

I would ask same thing. Medicare or Medicare managed care/advantage?

Is this the same podiatrist you work for?

If possible can you contact carrier in writing and make formal request for all EOB's related to this provider? under FOI (freedom of information) you can .. need to know more about the insurance plan first though, as ERISA claims are with Dept of Labor and non ERISA (church, govt, state) are with state dept of insurance and you might need one or the other to help you with this request.

She has a Medicare Advantage plan, and does have a copay if there is an office visit charge. But, as I'm sure you all know, if there is no e&m, only the routine foot care charge, some insurance plans don't apply the copay, but pays the physician 100% of the allowable for the services, clearly showing on the eob $0 patient responsibility. I know it depends on the plan, I have ones that apply a copay no matter what, and others where there is no copay unless there is an e&m charge. I checked all the eobs my grandmother had (2014) and there was $0 patient responsibility on every one.

Now, I know with a new plan, or new patient, you don't always know which way it's going to go, so we do collect the copay. But as soon as I see that the plan is not applying it, I instruct the front desk to not collect the copay unless the doctor checks off an office visit. I don't let it go on for years.. and I DON'T tell the patients they have to pay more because Medicare is cutting back.... I think that is what gets me the most angry. Taking advantage of seniors who are not savvy about medical insurance....

And no, this is not the same podiatrist I work for! It would never have happened!  ;)
My mom is close by and can facilitate any requests to the insurance company.
At least for 2014, this is a black and white issue, I have the receipts of copays paid by my grandmother, and the eobs showing zero responsibility.


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