Wiki insurance overpayments

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nkorab

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this happens to us all the time. A patient has 2 insurance plans that we are contracted with. We bill the prime one, they do not pay anything, but apply a contractual coinsurance amount. We then bill this amount to the 2nd insurance. And the 2nd insurance processes the claim as if they are prime due to no payment from the prime. Therefore we have an overpayment. How do we correct this? and is this correct? should we be refunding the 2nd insurance or adjust our contracted amounts? I know medicare does a similar equation, and we just don't know what to do with the overpayments??

Thanks all.:confused:
 
Hi there,
How are you sending out the claims?
Here is your technical answer; if you are sending these out using a clearing house you will need to verify that both you and the clearing house are set up to process secondary claims. The clearing house is looking for "loops" or information to send the claims to the primary and secondary insurance accordingly this would be typically provided by your billing software. If that's the case you will want to capture the information and contact your Healthcare IT to research that further. Test and validate the process with the clearing house.

Business answer;
Call the insurance to get further information on their overpayment procedures, some insurances will allow you to hold the funds and apply to future payments and others will want the money back.

Review your policy if you can apply the payment or wait until you receive the corrected payment or EOB report.

A workaround method to return the over payments that I use is, get the Primary insurance EOB report that indicates the contractual coinsurance amount and send this with the overpayment, CMS 1500 corrected form and with a letter to the secondary insurance so they can process and update the claims and payments. Mind you too that you have 60 days to return the overpayment.

If you continue to have a trend of over payments, you may end up on the insurance's radar for an audit or other actions. Keep everyone informed of the current status and remain in contact with the people who are involved in working on the case.
Good Luck, Jeff
 
Thanks Jeff for your insight.
We do send all our claims through a clearinghouse. So my task now will be to contact them and see if secondary claims are set up right.

I have a huge workload ahead of me and I imagine a lot of refunds to submit.

Thanks again.
Nancy
 
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