Insurance take backs

EileenC

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Hi out there
Has anyone ever had this situation and able to comment on it?
Recently, we found that one of our insurance carriers has been processing claims for one of our specialists with a pcp copay instead of a speacialist copay. Now, they have reprocessed claims for the last 6 years and taken back $60,000!!
Is there anything we can do??? This was their error and there is no way we will ever recoup this much from our patients, some of whom we probably will never be able to locate. I believe the carrier should take some responsibility instead of the provider bearing all the weight???
thanks for any input.
Eileen
Pennsylvania
 

CodingKing

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I'm not sure about ERISA plans (federal guidelines apply) but i checked two sites that list recoupment laws by state and they both said no laws in Pennsylvania.
 

pandi1024

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You need to appeal these. There are several valid appeal reasons including the length of time they are looking back and that they were in the best position to know how the claims should have been processed. I recommend getting help if this is the first time you are dealing with these. If you contact Karlene at medrevenue@bellsouth.net, you will get expert advise. Good luck!
 

PediatricPenguin

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I am unclear, the insurance company has been underpaying your facility (using a PCP copay) instead of the appropriate specialist copay? Then they reversed ALL those claims? $60,000 is certainly enough money to get a lawyer involved.

Did they withdraw funds directly from an account or are they requesting payment or are they withholding future payments until this amount is satisfied?
 

kell0870

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Out of network insurance recoupment

Hello,

I have a question. The billing company I work for is out of Utah but the Dr. I work for his clinic & surgical center resides out of Nevada and I see that State Regulations Regarding Recoupments show that Nevada "NO STATUE EXISTS" & under "TIME LIMIT FOR SEEKING REFUND OF OVER PAID CLAIM" shows "NONE".

I also see in another thread someone is saying, State laws that regulate this only apply to fully insured plans. Also, that patients covered under large group policies that are self-funded by their employers are not subject to state regulations.

My question is we are Out of Network on a majority of our claims. Does this apply to us? My boss wants me to do a letter to dispute the refund recoupments stating that there is a time limit of 12 months to 24 months.

Also, we have our patients sign a Assignment of Benefits/ERISA Authorized Representative Form with our patient packet allowing us to appeal or dispute on their behalf. We send in our claim & more than not we always have to appeal for payment. We then send in our appeal on a claim & the insurance company comes back stating we cannot appeal on the patients behalf w/out a Designation Authorized Representative Form. Then I mail out our "Assignment of Benefits/ERISA Authorized Representative Form. Then we will get back from the insurance company mainly BCBS, UHC & UMR at this point and they want their own Designation of Authorization form filled out by the patient. Then I will send a authorization form to the patient from there particular insurance company have patient sign & return to us. Then I mail off again along w/the insurance companies letter requesting the authorization and also another copy of our appeal as they requested. Then they come back again stating that the authorization form is not the one for this particular division of BCBS, UHC??? Really the wording is the same & one plan may be BCBS Federal & another out of Illinois. So frustrating. Can anyone tell me if this is legal? Are the insurance companies suppose to legally take our Assignment of Benefits/ERISA Authorized Representative Form as long as all the legal information is on our "Assignment of Benefits/ERISA Authorized Representative Form" is correct? Someone please help:/
 
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