Wiki Retroactive claim review questions

[Rindahlnicole]

We had an Anthem claim from 2012 that was retroactively reviewed and they retracted the payment. I went to seminar a little while back and I swore they said that private payers only have 12 months from the date of the payment to do a retroactive claim review in the state of VA is this true?? Help!!!

 

[ABonnell CPC]

Was the Anthem plan a Medicare or Medicaid managed care enrollment? If not, you would need to check your Anthem contract. Most standard contract do indicate the payer has 12 months from the date of payment to audit and request a refund.

 

[mitchellde]

Read the fine finer print also, that is usually if the payer paid the claim incorrectly, such as paid a non covered service as covered, or paid a covered patient that was not covered for that visit time frame, then they usually have a cap on the amount of time to discover this error and recoup the payment. If the claim was coded incorrectly and the documentation supports different codes that would not have paid if it had been submitted correctly, then usually there is no time limit for that type of recoupment.