Wiki Insurance company refusing to take back overpayment

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kimmcelderry@gmail.com

kimmcelderry@gmail.com

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Hi there, I have a patient with 2 BCBS policies. The secondary is a medicare advantage plan and has a higher allowable than the primary, so the claims are all overpaid. I called BCBS and they told me they "cant tell me how to run my books" and couldnt advise on what to do with the overpayments as they were paid according to the policy. They wont accept a refund. What do we do with these credits?! I have gotten many different answers, but I want to know what is right.

Thanks!
 
kimmcelderry@gmail.com said:
Hi there, I have a patient with 2 BCBS policies. The secondary is a medicare advantage plan and has a higher allowable than the primary, so the claims are all overpaid. I called BCBS and they told me they "cant tell me how to run my books" and couldnt advise on what to do with the overpayments as they were paid according to the policy. They wont accept a refund. What do we do with these credits?! I have gotten many different answers, but I want to know what is right.

Thanks!
Click to expand...
Most BC plans have an overpayment form or online process. If not, send in a reconsideration and they will reprocess the claims properly resulting in a takeback. Vanessa
 
In the past, we have back-adjusted the overpayment amount, then applied the overpayment, per the insurance company's instructions.

So the allowed amount becomes secondary insurance's allowed amount, not the primary, and the balance is zero. On these, when you check benefits, it will often say "coordinates benefits = NO".
 
SharonCollachi said:
In the past, we have back-adjusted the overpayment amount, then applied the overpayment, per the insurance company's instructions.

So the allowed amount becomes secondary insurance's allowed amount, not the primary, and the balance is zero. On these, when you check benefits, it will often say "coordinates benefits = NO".
Click to expand...

I agree.

We have this happen from time to time, where the secondary allowed amount is greater than the primary allowed amount.

It's not an overpayment. You just have to correct your adjustments.
 
Based on what you've said, I'd generally agree with the responses above. There is legal precedent that if an overpayment was made by an insurance company that was not due to the fault of the provider's billing (i.e. you did not submit an incorrect or fraudulent claim) and they have confirmed that the payment is correct, then you are likely not under a legal obligation to refund it. If, between the two policies, they have paid more than billed charge, then there may be a question as to whether the overpayment belongs to the provider or to the patient, however. But if it's just a matter of one payer allowing more than the other, I'd agree with making the adjustments to the account.
 
You might want to check with the Medicare Advantage plan to see if they are listed as the primary insurer. Many times the patients think one thing but in actuality its another. If they are over 65 and still working or they are covered on their spouses insurance, there are rules as to which insurance is paying primary. In Ohio if their employer or their spouses employer employs less than 20 people the Medicare may pay primary and the other insurance may pay second. This might explain the credits that you are trying to deal with. There is usually a website you can go to to verify who is primary and who is secondary. if you check your Medicare website for coordination of benefits with Medicare as a secondary payer there should be some guidelines. The money may be yours to keep once you figure out "who's on first and what's on second?" sorry i just had to say that! Frequently patients don't understand their insurance coverage so they give us as the caregiver inaccurate information.

I think you may have been paid correctly but will have to verify who is paying primary and who is paying secondary.
Good Luck, I hope this helps.

Davieda Skobel CLPN, CPC
Ohio
 
Thank you for the responses. The 2 BCBS policies both have the same coordination of benefits. The secondary's allowable is higher, causing overpayments. My supervisor and I agree that we will just adjust the contractual write-offs to match the secondary's payments since they will not take back the difference.
 
Wondering if anyone can give me some advice. My question is similar to the one above. I have a patient that has Medicare Part B primary, Cigna secondary, which looks like a retirement plan under his spouse, and an UHC AARP supplement Plan L. All three plans have paid causing an overpayment. I have contacted the Cigna plan and the supplemental and they both have stated that they have paid per terms of their coverage. Both plans the allowable is higher. Neither of them would advise which was secondary or tertiary both stated they paid correctly. Would I just make the similar adjustments to the account as mentioned above or should I send a refund to the patient? A colleague advised to refund patient for the third insurance payment. Medicare forwarded payment info to both policies and to my knowledge our office never billed either policy, if that matters.
 
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