Neurology & Pain Management Coding Alert

Take timely corrective action if you discover an overpayment.

Did you know that you're obligated to refund overpayments to payers regardless of primary-versus-secondary issues between the payers? If not, it's time for a refresher in how to navigate the often convoluted path to accurate primary-secondary payer claims.

Beware: "Keeping an overpayment might be deemed to be fraud or a possible kickback" warns coding, billing, and practice management consultant Steven M. Verno, CMBS, CMSCS, CEMCS, CPM-MCS, in Orlando, Fla.

Stay Compliant

Both the OIG's compliance guidance for physicians and its guidance for third-party billing companies address overpayment refunding. As a healthcare provider, you have a legal obligation to repay any discovered overpayments.

If you discover an overpayment, your practice should be prepared to refund one of the payers -- or sometimes the patient -- the money due.

Pointer: Don't send refunds to payers until you have specific information on where to send the money. When you find out about an overpayment because of primary and secondary payer mix-ups, send a letter to the payer explaining the situation, and wait for them to tell you where to send the repayment check.

If a patient presents you with information on what she thinks is her primary insurance, and your practice finds out much later that it was her secondary insurance but you were paid, talk with the payer.

Ideally: Patients are responsible for being compliant, and they can get into trouble for insurance fraud by not following their insurance payers' rules. If the patient makes a mistake and gives the secondary payer as the primary, the insurance company will hopefully catch the error and then pay at the secondary rate.

Reality: Sometimes patients and payers make mistakes. If the secondary insurance paid the claims as a primary because it was unaware of other insurance and the practice also did not have any knowledge of the primary payer, then the practice will need to take corrective action. "The practice would likely need to send in corrected billing so that the primary insurance can process the claim and then the secondary payer review the patient's responsibility/Coordination of benefits (COB)," says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, CO.

Be Proactive

If you find out about the error -- for example, if the patient calls your office several months later and explains the situation -- you should call the payer and let it know of the error. Often the payer may not do anything because so much time has passed, or it may work directly with the patient to solve the problem.

"Contact should be made with the overpaying insurance, first, to identify what happened to create the overpayment; then a refund should be initiated as per instructions from the insurance company," says Linda Huckaby, CMA (AAMA), with Carolina Medical Rehabilitation in Greenville, S.C.