AAPC - Back to school
Results 1 to 3 of 3

Thread: Some insight please

  1. #1

    Default Some insight please

    AAPC: Back to School
    Hi Everyone,
    I hope someone could give me some insight on how to handle this scenerio.
    I just recieved an an eligibility audit to identify dependents that are not elibible under The Empire Plan (NYSHIP). I have 3 patients from 2009 that were not eligible as dependents and empire wants a recovery for these patients. As a physicians office do we have any right to tell Empire to recover this from the patient? Also I don't want them to take an automatic offset out for these patients if I am going to fight this. Does anyone have anyone have any ideas?

    Hhighly appreciated

  2. #2
    Join Date
    Apr 2007
    Spokane, WA


    Most insurance companies have up to 3 years to recover payments. If they paid on these patients and then later found they were not in fact eligible for the dates of service they recover the payments from the provider. Once payments are recovered you can then bill the patient as "coverage not in effect" and they are held financially responsible. In the meantime I would try to figure out if the patients had other insurance that was active for the dates of service.

    The insurance company will not recover money from a patient as the patient was not paid. The money comes from the physician that was paid. Automatic recoveries are much less hassle and work than issuing a refund. Just my two cents.

    Hope that helped.

  3. #3


    Under NY state statute 3224-b, insurers are prohibited from demanding a refund after 24 months from the date the claim was paid, unless fraud is involved, intentional misconduct, or is initiated under a self-funded plan or is required by a state or federal government program. A thirty day notice must be provided.

    The fact is, Govt. carriers can require and will get the money back. Fighting it really isn't an option. Medicaid repayment is required under the participation agreement, just like Medicare.

    You will have to look to the patient for payment. Repayment is typically required within 30 days.
    Cyndee Weston, CPC, CMC, CMRS
    American Medical Billing Association
    AMBACode Coding Software
    2015 AMBA National Medical Billing Conference

Similar Threads

  1. Can someone give me some insight
    By colleensso in forum Auditing General Discussion
    Replies: 0
    Last Post: 09-09-2010, 08:58 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.