Settlement of a liability claim can take years and insurance carriers have a long memory.
Unfortunately, providers get caught in the middle of the money muddle of who should pay and who should refund an overpayment.
For this reason, providers need to review overpayment demands carefully. First, know how and if any managed care contract terms apply to coordination/subrogation situations. However, if no contract exists, the insurance carrier recourse may be to collect the overpayment from the patient. Appeal Solutions has developed a sample letter for requesting a detailed response to an insurance carrier’s refund/recoupment demand involving a liability settlement:
Dear Payer,
We are in receipt of a refund request regarding the above referenced claim. It is our understanding that your organization has received information regarding a liability settlement and/or other benefits for the medical treatment in question.
This letter is to notify you that this request is contested. It does not appear that your company has provided sufficient information regarding the coordination/subrogation clause as it reads in the applicable insurance policy.
As you are likely aware, retroactive adverse determinations involve a number of compliance issues related to coordination of benefits, prompt payment, prompt claim decision-making and, if a precertification was extended, utilization review laws. Therefore, we request a written review of this decision by your compliance department with attention to state and federal protections related to retroactive benefit determinations. Specifically, it would appear that your recourse in situations involving coordination of benefits would be between your organization and the party receiving the liability settlement.
Further, please indicate if your insured has been advised of this retroactive adverse determination and, if so, please clarify if your insured concurs with your adverse benefit determination and has been advised of, and waived, the right to appeal. Further, if your request for repayment is maintained, please provide clarification regarding any appeal rights available to the provider or the health plan assignee. This will assist us with our review of this matter.
Sincerely,
(your organization)
This letter may be customized for your organization to cite contract specifics applicable to coordination of benefits/subrogation. For more information about developing more protective contract language and/or using contract language in appeals and requests for information, contact Appeal Solutions at 888-399-4925.
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