Wiki Overpayment Request for dos over a year ago.

[drakena74]

I work as a biller for an ASC in Southern California. August of 2012 we started getting overpayment requests from out of state insurances asking for money back. We originally couldn't get a lot out of the insurance companies because we were out of network, we had to go through our local, Anthem Blue Cross, to find out what's going on. End of August I was finally able to get an answer; "New cost ratios have been updated for non-par ASCs" by Anthem Blue Cross of CA. When they updated the cost ratio it effected claims dated back to 2011 (over a year ago) and we are still getting overpmt requests. I did speak with a rep @ BCBS of Ill and she stated that in their system there was a note to check in to this. The BCBS rep was able to speak with a IT tech @ Anthem Blue Cross of CA, and he stated that it was a system glitch and didn't know when it would be fixed.

We did go back and file 2nd level appeals with this information, but it didn't help at all they still denied them. We did try to speak with a lawyer, but he wasn't much help either.

Please help, how far back can insurance in CA go back to recoup overpayments? This whole thing doesn't sound right to me, but not sure what the next step is. Can any one help? for CA claims, If Anthem dictates to out of state BCBS ins what they need to pay, do we have to go by recoupment law in that state or does it still fall under CA jurisdication? Any thought?

 

[Top Gun Audit School]

Hi Jennifer -- there are other ways to fight these kinds of denials... here is a free report by a friend of mine who is a lawyer...

This is from the introduction:

"One of the things I have seen time and again is how so many providers are burdened
with some misconceptions about fighting back, fighting to get paid right when they file a
claim, and fighting to keep their payments when they are later denied and the payor
takes back the money. All the payors want to hold the providers accountable, and that is
as it should be. But the payors should also be held accountable. I have had fantastic
success filing appeals for my clients, because I know how to ignore those misconceptions
and hold payors accountable.

So let me share some things with you, so you can dispel any misconceptions you might
have about appealing denials, and especially about where “the power” lies in healthcare.
Armed with what I'm about to tell you, then you can hopefully join me and hold the
payors accountable, too."​

He shares 9 Tips that I think you could use... the report is free and short (13 pgs), but powerful:"The Power To Get PAID".

Good Luck!
Ernie de los Santos
Faculty Chair
Appeal Academy

 

[airart]

Request for Refunds

BCBS always goes by the rules of the members Home Plan for most everything when it comes to their policies and reimbursement.

I found this handy little tool on recoupment/refund laws by state that I keep handy, also saved on a thumb drive and on my PC so I don't lose it. I also have started another one recently, transferred their info with my updated and just add to it when new things come up.

Here is the link:
I haven't checked all states on the laws listed, but so far they have been accurate on the ones I have. Some needed updated. Check the states you need on the state web pages prior to contacting the carrier.
http://www.mtbc.com/files/insurance refund recoupment laws.pdf

For California it states time limit for seeking refund of overpaid claim:

Reimbursement request for the overpayment of a claim shall not be made, unless a written request for reimbursement is sent to provider within 365 days of the date of payment on the overpaid claims.

Exception:
Time limit of 365 days shall not apply if the overpayment was caused in whole or in part by fraud or misrepresentation on the part of the provider.

For Illinois there is no information on time limit for seeking refund of overpaid claim.

Here is an article on this topic.

They also list below the states that have time limits established. I would fight BCBS on the California time limit statute if your dates of service are outside the 365 days.

http://www.aaoms.org/pm_news.php?id=26

 

[drakena74]

Thanks everyone for your help.