Do we have to send a refund to BCBS?

jennaduncan

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Our office has received a refund recovery request for BCBS Federal. We verified the patients insurance at the time of service. He had Tricare and BCBS, and we verified that BCBS is primary. After discussing this w/ the patient he told me that he didn't understand why he had to use BCBS because that was his Ex-wife's insurance and that had been divorced for years, she just never took him off her plan. That was February 2012. On June 30th we got the refund request stating his coverage terminated 4/1/2010. Can they legally do this? He was not able to use his TRICARE because the BCBS was primary. They are asking for close to 5,000.
 

btadlock1

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Our office has received a refund recovery request for BCBS Federal. We verified the patients insurance at the time of service. He had Tricare and BCBS, and we verified that BCBS is primary. After discussing this w/ the patient he told me that he didn't understand why he had to use BCBS because that was his Ex-wife's insurance and that had been divorced for years, she just never took him off her plan. That was February 2012. On June 30th we got the refund request stating his coverage terminated 4/1/2010. Can they legally do this? He was not able to use his TRICARE because the BCBS was primary. They are asking for close to 5,000.
I'd approach this by trying to appeal, first...
Can you prove that you verified coverage at the time of service? (Do you have any printouts, account notes with a rep's name & ID #, or other forms of verification?) You shouldn't really be on the hook for all of that money, just because someone over there, screwed up. If you can prove that they screwed up, then you might be able to get them to reverse their decision...but that's going to be an uphill battle, either way.
They'll tell you that the patient is responsible for the amount, knowing that they won't have to deal with him - even though they made the mistake. (After all, how did he manage to go 2 years using an insurance policy that he claims he shouldn't have been on? Was his insurance information not verified, periodically?)

There's a slim chance the appeal might work, but I would bet that it fails - the main reason you'd want to do it, is because if you do end up having to bill the patient, somewhere down the line, you can honestly say that you did everything that you could to try to fix the problem, before sticking him with the bill.

The second option (which has a much higher likelihood of being successful), is to round up those refund requests, and obtain the original EOB's for the claims, and submit them to Tricare, with the claims. Tricare may not accept refund requests as proof of timely filing, but I know for a fact that BCBS Federal can generate new EOB's, with a current processing date, showing that all of the claims have been denied - you just have to ask them nicely.

In effect, it's like BCBS will have just processed the claims today, and denied them - the timely filing limitation is waived, when claims are submitted within 90 days from the processing date on the EOB, for secondary payers. Tricare has no choice, but to treat these as secondary claims, that were recently processed.

If all else fails, unfortunately, you will have to refund the money, and bill the patient. Hope that helps! ;)
 

jennaduncan

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His EX Wife just notified the insurance company that they divorced in 2010. So it seems to me that they are retro-ing his term date to the date the divorce was final and not when she called to remove him from her plan.
 

btadlock1

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His EX Wife just notified the insurance company that they divorced in 2010. So it seems to me that they are retro-ing his term date to the date the divorce was final and not when she called to remove him from her plan.
Yep - they can do that. You should be able to get paid by Tricare, if you submit the claims with current EOB's, showing that they've been denied. Send a letter explaining that, at the time of service, BCBS was listed as the active primary payer for the claims, but that they've rescinded coverage. It may take an appeal to get them to process it correctly, but there's no reason it shouldn't pay. I've had to deal with quite a few refund situations like that - as long as you can get the new EOB's, you shouldn't have any trouble.;)
 

suemt

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Persistence is the key! Also, be sure to retain proof of the date you submitted the request to Tricare.
 

drakena74

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I would also send a copy of the refund request from BCBS with the appeal to TriCare because it states on there that the patient was retroactively terminated.
 
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