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Hey, greetings, friends and colleagues. It’s Sam Collins, the coding and billing expert for you, for the profession, for ChiroSecure. Most importantly, really for you though obviously. There’s always changes, there’s updates. Over the last few months, we’ve gone over things like ICD 10 updates. We’ve dealt with insurance companies dealing with denials.
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We’ve also talked about the new rules re regarding collections. However, something that’s come up this past month quite a bit that I thought we’d wanna address our insurance refunds. So let’s go to the slides. What are we talking about when an insurance says they want a refund? Let’s say the insurance company sends you a letter and it says, Hey, it turns out we overpaid you.
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We paid you more money than we should have. We want it back. We have to know we have rights, we have things that we can deal with, and I wanna make sure there’s some clarity here on when you can dispute it, and then maybe when you cannot. But at the end of the day, I wanna make sure we’re getting paid and not having to pay something back.
So when an insurance company like this one, request a refund for an overpayment. Do we have to refund? Let’s talk about that. Let’s get into some details. Let’s look at this one. This is under a federal plan, and it says in regards to the request for repayment for the claim, the request made to you was voluntary.
Now, it’s interesting that this carrier decided to tell you that it’s actually voluntary because for the most part it is. Unless you’re in network. So now here becomes the biggest problem. When you’re in network with an insurance, understand that you give away a lot of rights. One of the rights you give away is the right to dispute that.
By example, they could say, Hey, if we make a mistake, even though it’s our mistake and we pay you, we can make you pay the money back or take it back. That’s part of that contract. Understand when you join an insurance, you’re giving some of that away. It’s part of the trade though. When you join an insurance, what’s always the issue?
When I join, I’m expecting I’m gonna get more patients. You’re gonna refer me more. Therefore, the lesser money I get in reimbursement and or the potential recoupment I’ll deal with because of volume. But I do want to hit that it’s voluntary otherwise. And that’s why this says it was voluntary and it says because you are an in-network provider, you do not have to pay it back.
If the overpayment. Was discovered after 365 days. So you’re saying wait a minute, Sam, you just said if I’m in network, I have to refund it. Yes. If it’s within the statute of limitations in network, you do. But if it’s outside of the statute of limitations, you don’t. So there’s several ways we have protection here.
If you’re out of network, actually you can dispute it pretty strongly that you don’t have to refund it because it’s their mistake. There’s actually case law that helps us. Let’s take a look at this case law. Now look, it’s dating back. Some 50 years now it says in Federated Mutual Insurance Company versus Good Samaritan Hospital.
The court held that an insurer could not recover an overpayment made by mistake. Reasoning that the insurance company is in the best position to know the policy limits and are and must bear the responsibility for its own mistakes. Think of it. Let’s say you, where you do a good insurance verification.
The plan says it covers 25 visits. You think, fantastic. We’ll, bill, you get paid for 25 and then six months later, a year later, whatever, they send you a letter and it says, Hey, it turns out Mr. Jones had already used those 25 visits as a physical therapist or maybe an acupuncturist or maybe another chiro.
Think about that. Whose fault is that? Who should have known 25 visits were used when you called? They said they had ’em. You go, great. I billed it. They then later discovered that they didn’t do it properly. It’s their own mistake. They have to bear responsibility. There’s another part of case law.
This is City of Hope versus Western Life Insurance, and it says, or the court found that absence fraud. Healthcare provider is not legally obligated to refund payments received from an insurer that later determines they were made in error. They have to have a certain level of responsibility. You’re not getting more than you Bill.
Let’s talk about this for a moment. What if an insurance pays a duplicate payment to you? Okay, that one we have to refund ’cause we actually receive more than we bill. But let’s say that it paid a visit, it shouldn’t have or paid more. Not more than you billed, but more than they allowed.
Whose fault is that? Is that you to go back? Now, in theory, let’s think about that. Who actually owes the money? If the patient already used up their visits, who actually owes the money? The patient does. Why does the insurance come to us? Because we’re assuming, we’re afraid they’re the deep pockets.
Oh, I better refund it. I’m gonna push back. There is good case law for us here that’s been there for a while. Always push back, particularly if you are out of network. Now, if you’re in network, we do have to deal with statute of limitations. However, notice even carriers know it because look at, this is one from Aetna Insurance.
Where they’re literally saying, our records indicate the overpayment as note, as noted on this document, is not eligible to be offset. And you’ll notice that when you’re in network, frankly, often they’ll just pull it out. But if it’s not legally within that meaning the statute of limitations, they can’t.
So they’re saying, therefore we request that you must make a check payable to us. Now, you know what my statement would be? No thank you. Why do I have to pay you when the law says I don’t? Can you imagine? What if an insurance company. Said to you, Hey, we have a 90 day limit to bill insurance, and a lot of them do.
A lot of the anthems and sickness do have 90 days. If you send it at a hundred days, do they say, oh, it’s okay, we’ll accept the claim. No, they don’t. So if they miss the statute of limitation, they’ve missed it. So here’s the statute of limitations for all states. And you can see for some states like Connecticut, it’s five years.
That’s a long time. Others could be two years, 18 months, some as little as 90 days or a year. A typical most people think is a year. But you can see here, actually it’s not. ’cause there’s some that are a little more, some or less notice some states. Don’t have any statute, which to me means it defaults to the national statute, which is one year.
Now notice for Louisiana, I love that they only have a time limit based upon if they give you 30 days to submit a claim, they only get 30 days to seek a recoupment. So even if you are in network, let’s say you get one from an insurance, you’re in network and they go, oh, we discovered this two years ago.
That’s too late. If it’s too late to send the claim, it’s too late for them to recoup it. So I have a letter for that. Now, particularly for those of you who are network members with me, and this might be a good reason to attend a seminar, be a network member. We have a letter that deals with this refund very specifically.
This is one I use in the state of Texas, but I have one for every state, and it talks about the supporting case law. Federated Mutual Insurance, city of Hope. Those two cases. But notice here, under Texas Insurance Code, an insurance must complete an audit conducted after 180 days. If it’s beyond 180 days, they can’t seek it back, so don’t be afraid to push back if an insurance is requesting a refund, if it’s within the time limit or you’re in network.
Okay, but if you’re out of network, my answer is always no. Don’t be afraid to push back. Again, if you’re a network member with me, request the one specific to your state with case law, but also your state statute. Don’t assume that they’re going to necessarily press you. They’re looking to see if you’re willing to pay.
That’s why it says it’s voluntary. Don’t be afraid to push back. That’s why we always wanna fight for your money. That’s why we always wanna make sure you’re getting paid, things are getting tighter, they’re squeezing down. Please make sure the law is on your side when it comes to this. When there’s a refund request, you can push back.
Now if they literally pay you more than you bill or paid it twice, different issue, but that’s not the case here. They’re just simply going, oh, we made a mistake. Too bad. Who do they go after if they want the patient? ’cause I’m not coming after me. So here’s what we’re gonna do. Always be help to you HJ Ross.
We do seminars, we have our platinum network, and again, network members, reach out to me, set up your Zoom and or request the document. I’ll see you soon everyone. Take care.
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