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Some insight please

  1. Default Some insight please
    Medical Coding Books
    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
    SSO

  2. #2
    Default
    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. Default
    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
    www.ambanet.net/AMBA.htm
    AMBACode Coding Software
    http://www.ambacode.net
    2015 AMBA National Medical Billing Conference
    http://www.ambanet.net/2015.htm

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