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Hello there friends, welcome in. This is ChiroSecure, as let’s make sure. You’re getting paid. That’s what I’m going to call it. This is Sam Collins, your coding and billing expert. And I want to talk about a question that’s come up quite a bit. As you’re aware, I do seminars. I also do a service we call The Network, where I help you day to day.
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A question I’ve gotten a lot of this year, in fact, a lot in the last couple of months is, Sam, I got a letter from an insurance that says, pay me back. In fact, I’ve had a few that said they just took the money. What do you do in a case where an insurance company says we paid you money and we should have?
And we want it back. Where does that put you? How are you supposed to deal with this? Are you supposed to go to the patient? What do we do with the insurance? Let’s talk about how the law backs you up, because it’s frustrating. You do everything you can. You do it properly, you verify, and you bill. You send the bill, you get paid good, you move on.
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Now they come back sometimes much later asking for money back. Let’s talk about where you can fight back on this and push back, because the insurance company is often, Assuming you don’t know your rights or the laws. So let’s go to the laws. Let’s talk specifically on the slides here about the statutes of limitations when it comes to recoupment.
When an insurance company says we’ve paid something wrong, they have rules that they have to follow whether or not they can force you to repay it. on a statute of limitations, just like billing. For example, if you’re billing to, say, a anthem policy, many of those can have as little as 90 days, maybe 180, maybe one year, but there’s a statute of limitations we’re all aware of.
If you don’t bill within that time, they can say, oh, it’s too late. The same thing applies when they’re recouping money. There’s laws that do that. So here’s a representation. I won’t say this is going to be every state, but to give you an example, under federal rule, it’s one year. So it’s one year from the date that it’s been paid, then they can recoup, of course, for any reason.
However, notice some states have no statute. Alaska, Hawaii, Idaho, and so forth. What happens if there’s no statute of limitations? I’m going to default to the federal, which means one year. But notice other states like Georgia, 90 days. So if they send it to you 120 days later, you can still go fly a kite, essentially.
It’s too late. Just like they would do if we didn’t send a bill. So don’t be afraid to push back. Notice some states though, like Connecticut, Oh my God, five years. That’s a pretty long time. So really where do we fight back on this? When an insurance company says, Hey, we’ve paid you wrong. We want the money back.
Let’s look again, how the laws help us. Take a look under this federal request. This is a federal employees program, Blue Cross Blue Shield. And it says here, Dear Building Department, in regards to the request for overpayment of the claim, the request made to you was voluntary. Excuse me, voluntary.
Whoa, wait a minute. That’s telling you right there. Do you have to send it back? Now, not often will they put this in the letter because, look, they’re giving you the reason why it’s voluntary. It says, because you are an in network provider, you do not have to pay back any overpayment if the overpayment was discovered after 365 days, meaning more than a year.
So that’s that federal statute. So notice, You’re not in, you’re in network, but because it’s over one year. Now, there’s a difference when you’re in or out of network, but let’s just deal with that as an out of network provider. It’s one year. Even if you’re in network, it’s one year. If you’re in network, generically, you’re going to have a contract that will supersede and says, we know that there’s been a mistake, but you have to pay it back.
Notice here, they’re saying, no, it’s voluntary. For sure, look to see, does it meet the statute of limitations? Just like a bill. If you send a bill late, no matter how legitimate the bill is, no matter the mistake, they don’t have to pay it. Okay, so I want to push back on this as well. Let’s talk about where you stand on laws when it comes to this.
Here’s a letter. I’ve dealt with this for years. I’ve been teaching seminars now for over 25 years. This law has been around a while and it goes through what happens when an insurance company sends you a letter that says, we want you to pay it back. My first rule is No. Why would I pay it back? Now, what if you were paid twice?
Okay, I get that. You have to pay back a duplicate payment. Or what if they paid you more than you billed? But let’s take an instance where The plan only has 15 chiropractic slash PT visits and they later send you a claim. They paid it, but they send you something saying, hey, we already paid 15 PT visits and we forgot.
Therefore, you have to pay it back. My answer is absolutely not. They’re in the best position to know their coverage. Why can they come back now and say It was our mistake so pay it back. No, not so fast. Let’s take a look at what the law say to us here. It says, I would like to bring your attention to the cases of the Federated Mutual Insurance versus Good Samaritan Hospital.
Notice this date dates back to 1974. Okay, how long ago was that? 50 years. So this is not new. They’re assuming you don’t know this. And it says here, the insurance company is in the best position to know what the policy limits are and must bear the responsibility of their own mistake. They paid you for more visits than what the plan allowed.
Is that your mistake? No, it was theirs. What they’re saying is, you be our collection company. You go chase the patient. My answer, no. You chase your insured. They’re the ones that, you were the one that made the mistake. Why is it my responsibility to be your collection company? In fact, it goes on to here to say, and this is one versus Western Mutual Insurance versus City of Hope.
In the absence of fraud, a healthcare provider is not legally obligated to refund payments it receives from an insurer if the insurer subsequently determines that they were paid in error. That something about it was wrong, you send a claim, what are you supposed to do? They pay it, as our assumption, and go, Wait a minute, let me hold on to it for a while because maybe it was wrong.
No. Always push back on this. Don’t be afraid to send this type of letter highlighting the case law. They know it. They assume you don’t. But what about it you say, but Sam, they collected the money from another payment. If you’re in network, they can do that. Part of the contract. That’s part of what we signed up for.
So in that instance, even when it is their mistake, but when you’re out of network, no. Or what if you’re in network, but it’s beyond the statute of limitations? So if you’re in network, check the statute of limitations. If it’s beyond statute of limitations, you’re going to push back. Now if they’ve already recouped it, possession is nine tenths of the law, so now we’ve got an issue.
Are we going to go back to them and try to push the issue to be paid? I had an office, this has been a while ago, but I had an office that they recouped some six thousand dollars from him. He pushed back, they wouldn’t do it, he took them to court. He won. He not only won the claim to get the money paid back to him, but damages as well as his attorney fees.
Now, that was worth it for 6, 000 plus all of that, but what if you’re saying, Sam, it’s a couple hundred dollars? Maybe not, but I would still push back with the letter at the very least to say, Hey, wait a minute. Based on this case law, this shouldn’t happen. If they’ve not already recouped it often.
Just ignoring it might be the thing. Because what if they deduct it from a current payment? They better be a network for them to do that. That’s why that one said we can’t do it. Because it’s voluntary. Or did they say they can’t? Let’s take a look at one that did. Here’s one from Aetna. And it says here, and I’ll just go to the highlighted area.
Our records indicate that the overpayments, as noted on the enclosed document, is not eligible to be offset for a claim payment. In other words, maybe you’re out of network, so they can’t do it. Maybe it’s beyond statute of limitations. So here’s what they’re saying. Therefore, we must request you issue a check to us.
If I’m not forced or you’re saying voluntarily have you ever sent a claim saying, hey, I know I sent this claim late, but the services were legitimate, the patient really needed it, so please go ahead and pay us. What do you think their response is going to be? Absolutely not. So don’t be afraid to push back.
You get this type of letter saying, we like it because we can’t offset it. My answer is no, thank you. Do not be afraid to push back on these. The assumption is, You don’t know. If they send this letter out to a hundred docs and more than half of them pay it, it’s a win. What if some ignore it and don’t pay it?
I bet this has happened to you. What if you’ve ever just ignored that request? What are they gonna do? Nothing! Because they have no law to back them up. The law is on our side. Always know there’s gonna be people that are fighting for you that understand it. That’s what we do with the network. I know many of you might be members.
If you’re not, take a look. It’s how I help you day to day. I become part of your staff, coding, billing, documentation, as well as seminars. There’s always going to be support. ChiroSecure is your risk management. I’m here to make sure you get paid. Until next time everyone.
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