Wiki Humana PPI Overpayment Dispute

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CBarry21

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Has anyone had any luck disputing with Humana when they send a PPI Overpayment stating Claim is subject to Endoscopy & multiple surgery reduction? They originally paid the claim back on 10/27/2021 and now are requesting a refund for partial payment. I have 12 of these!!! I did call Humana and they told me that medical records most likely will not change the decision I was curious is this is true? Has anyone had any luck with a dispute?
 
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CBarry21 said:
Has anyone had any luck disputing with Humana when they send a PPI Overpayment stating Claim is subject to Endoscopy & multiple surgery reduction? They originally paid the claim back on 10/27/2021 and now are requesting a refund for partial payment. I have 12 of these!!! I did call Humana and they told me that medical records most likely will not change the decision I was curious is this is true? Has anyone had any luck with a dispute?
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I used to be in charge of reviewing refund requests for a large hospital system.

If an overpayment is valid, there isn't much that can be done. (Especially since the claims were so recent - if you were talking about claims from 3 years ago, I'd tell you to double-check your contractual agreement to see how long they can request adjusted payments. But for a claim that just paid in October, it is most likely well within the allowable time frame to correct an overpayment.)

However, if an overpayment request is NOT valid, then I would dispute that. Were these claims Medicare, Medicaid, or Commercial? If Commercial, what does your contractual agreement say about reductions in reimbursement for multiple surgeries?

When disputing an overpayment request, it's important to be able to demonstrate why the original payment was correct under the terms of your contractual agreement. It doesn't sound like this is a request about medical necessity, so sending medical records alone won't be sufficient.

Good luck!
 
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I have not tried an appeal to Humana, but I'm very familiar with this situation. Multiple surgery reductions are governed by provider contracts and payment policies. Payers frequently process the reductions incorrectly on endoscopy claims because the formula for pricing these is very difficult to program into a claims system, but auditors will find the errors after the fact. They're correct in telling you that medical records will not make any difference in any appeal - it's an issue with calculation of the payment, not with the records or the coding.

You would only be able to successfully appeal these if you can 1) show language in your contract or in their policies that shows that the original claim was paid correctly and therefore should not be recovered; or 2) the terms your contract places some time limitations or restrictions on the payer's right to recovery payments and their request is outside those specific limits. So I'd recommend starting by reviewing your contract and Humana's multiple procedure reduction policy to determine what is the correct payment and whether or not the contract allows them to recover this payment. That will tell you whether or not you have a case for an appeal.
 
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