How to Handle Refund Requests
If you've been experiencing an increased number of refund requests from insurance companies for payments already made, you are not alone. I have heard more reports of doctors receiving requests for money to be returned to payers for ‘incorrect payment'. These requests seem to be indiscriminate, since the billing procedures in offices receiving these refund requests have not changed. So what has changed?
Insurance companies and government payers have hired audit companies in an attempt to reduce the amount of claims payments that the payer is paying out. These audit companies are usually paid a contingency fee, and they are looking for any actual and potential claim payment inaccuracies. Often a demand for refund is sent based on a potential error, not an actual error.
Before you return the money requested by the insurance company, you need to make sure that the payer did, in fact, send you an incorrect payment. Brush up on your rights, and make sure that the payer is following correct procedures, before you send them a check for the overpayment.
Most states have laws addressing the procedures required to request a payment refund. Make sure that the payer has followed the requirements required by your state. At the very least, make sure that the payer provides a specific reason for the request. You need this information to compare it with your billing and treatment records to see if there is an actual refund due to the payer. Dates, procedures, or billing codes may all be in dispute, and if you have good records you can easily dispute the refund request.
Understand the language within the policy or provider agreement under which the payer is requesting the refund. Many provider agreements have a ‘due and owing' clause within the agreement. If the provider fulfills all of the requirements outlined by the agreement, then the benefits are ‘due and owing'. Simply knowing the language and procedures required by the policy or provider agreement may give you the information you need to refuse some demands for refunds by the payer.
Knowing the ‘extent or existence of treatment' rules utilized by the payer may give you an advantage in refund request disputes. If the insurance company required pre-authorization, or if the benefits were exhausted, or the treatment not covered, but the insurance company paid you anyway, you may be entitled to keep the money. If the insurance company claims that they incorrectly paid a claim through a mistake that it made, you may be allowed to keep the overpayment. Several courts have ruled that if the company didn't follow its own procedures, it is at fault, and the provider is due its fee.
Most states also have a statute of limitations which controls the timing of refund requests. Make sure that the request for the refund is filed in a timely manner, or the request will not be valid.
Most requests for payment refunds can be resolved through accurate record keeping and billing. However, if after disputing the refund request with your factual data and the payer continues to demand the refund; you still feel that the refund request is erroneous; you can always obtain legal help. Some, if not many, of these refund requests are similar to initial claim denials. If the company routinely sends out refund requests, a certain percentage will be honored, and the expense will be justified. Turn the tables on the payer and make it more expensive to request the refund from your office, and they will back down.
Remember that many of these refund requests are just fishing expeditions, Knowing your rights and standing up for them will show the insurance company that you know the facts, and they will stop harassing you and go after easier prey.
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summary of the cases and comments on the contractual relationships between medical practice management companies and medical practices
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