Wiki BCBS Texas recoupment 4+ years later

[Stacey Walden]

I am in need of some guidance regarding a recoup recovery from BCBS (in Texas).

We billed BCBS on 01/11/2013 for 4 bilateral codes (30140, 31255, 31296, 31256) and BCBS paid in 2013.
Now in 10/2017 they have recoup'd indicating that they overpaid on the last 3 secondary codes (cutting each by another 50%). Their reasoning was that it was incorrectly priced.

What are the rules/regulations regarding recoupment in regards to timeframes and reasoning?

Any help is very appreciated!

 

[Bready]

Bcbs texas recoupment 4 years later

Check your contract with BCBS. If there is no recoupment time limit in the contract, then they can go back as far as they want.

Would you know the pricing for those procedures in 2013 per your contract with BCBS? If they really overpaid what your contract specified(allowing for multiple procedure reduction too)then you should refund them. If you don't, they will just recoup it from future claims. If you have a recoupment time limit already set-up, then you would tell them that per your contract they cannot go back farther than x number of years. Their loss in that case. If you don't have a time limit, when the contract comes up for renewal, your office many want to look into setting a recoupment time limit if you can.

Frustrating, I know.

 

[MonarchMedBill]

Senate bill 418!!!!!!!!!!!!!!!!!

BCBSTX does this often and I always fight it with Senate Bill 418!!! (Note: This will only work if the contract you have with the insurance company was signed AFTER 08/16/03.)

As signed by the Governor - June 2003

On Senate Bill 418 Prompt Pay Legislation, it states: Overpayments: Limits health plans from recovering an overpayment more than 180 days after the physician received the original payment. The health plan must notify the physician in writing the specific reason for the recovery. Ensures that the health plan will provide the physician with an opportunity to appeal if the physician disagrees with the request for recovery. The health plan may not attempt to recover until all appeal rights are exhausted.


This means that if the insurance company pays you and tries to recoup that payment AFTER 180 days, you can deny the repayment with a letter and a copy of this legislation. However, I believe you only have 30 days or so from their request to deny it. You can find a summary of the senate bill at this link: https://www.texmed.org/Template.aspx?id=3171

Even in the case of accidental duplicate claim submission, the insurance company only has 180 days to send the letter to the provider. Here is a Q&A on that found on: http://www.tdi.texas.gov/hprovider/ppsb418faq.html You should check out that link, there are a lot of great questions about this senate bill covered there!

Here is another answer regarding the same from that page:

Q: If the provider notifies the carrier of an overpayment and the carrier does not respond, or it is after 180 days, can the provider refuse to return the money? Is the provider required to notify the carrier at all?

A: You are entitled to the correct contracted rate and appropriate penalty, if any. Should you receive an amount in excess of these figures, responsible business practices suggest that you return that excess amount. However, SB 418 imposes no obligation that you do so, absent a timely written request from the carrier. Under 28 TAC §21.2818, the carrier has 180 days from the date the payment was received to request your return of an overpayment.

So in light of this information, I would most definitely write a letter to BCBSTX and send a copy of SB418 and tell them they have no rights to request the payment back.

Hope that helps!

 

[thomas7331]

Just a note of clarification - state insurance regulations only apply to fully insured commercial business. Most large employer groups are self-funded plans for which the payer only provides administrative services. Recoupments on claims for these groups would not be subject to the state Senate Bill restrictions.