Offer to Pay Back Incorrectly Paid Claims Once Other Payment Is Received
Refund/recoupment requests must be responded to promptly. Most providers consider their options to be (1) return requested overpayment, or (2) request an appeal of the retroactive denial. However, one option, particularly appropriate for situations involving coordination of benefits, is to offer to pay back incorrectly paid amounts after other payment has been secured.
Most providers have a refund/recoupment policy which requires assessment of overpayment requests for fairness of the request, potentially applicable compliance issues and contractual requirements. A number of state laws specify a time frame for provider response and Medicare Secondary Payment requires immediate payment of incorrectly paid Medicare benefits.
However, many overpayment requests are related to commercial coordination of benefits involving an erroneous payment by a secondary carrier. Commercial insurers typically have a written agreements with the policy holder requiring disclosure of other coverage. Based on that contractual relationship, carriers’ have clear legal rights in pursuing damages related to the patient/policyholders failure to provide complete coverage information. Therefore, the carrier’s duty to investigate coordination of benefits should be emphasized in any appeal related to refund requests by pointing out that the provider has limited legal rights or resources to demand coverage information after treatment has been rendered. Further, the provider may face barriers to primary coverage collection due to referral, pre-authorization and timely filing limitations.
After discussing the carrier’s duty to conduct coordination of benefits investigations, providers can extend a written offer to calculate and release the overpayment when primary policy benefits are received. Such an offer should also provide confirmation with documentation of the provider’s billing attempts with primary carrier. If this offer is accepted, the provider can collect the primary payment and then calculate more precisely how much is owed to the secondary payer.
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