RE: Insurance Refund Request

[Guest guest]

I don’t know about the “rule” but if the policy was expired and they paid a benefit by accident, the RIGHT thing to do is give the ins. company their money back. You’ll notice that benefits explanations quoted over the phone almost always include the caveat that “this is not a guarantee of payment”. They know how to cover their arses. Don Corvallis From: [mailto: ] On Behalf Of bluepearl2001@...Sent: Tuesday, January 18, 2011 12:07 PM Subject: Insurance Refund Request Greetings.What is the " RULE " , if there is one, for refunding insurance companies. I was paid for 3 treatments, then subsequently found out that the insurance had expired and will be asked for a refund. So their payment was a mistake on their end.BTW-They also told us that the patient's coverage went thru the end of the year... And they were wrong about that, too.Am I required to refund??Just asking...Ann DC

[Guest guest]

Well, they are a professional insurance company in the business of evaluating and paying/denying claims.  If they had all the relevant facts, IMO they should be regarded as waiving the right to reimbursement.  However, the 2009 legislature passed a law dealing with the issue, codified at ORS 743.912, which probably trumps any waiver arguments: “743.912 Refund of paid claims. (1) As used in this section, “refund” means the return, either directly or through an offset to a future claim, of some or all of a payment already received by a health care provider. (2) Except in the case of fraud or abuse of billing, and except as provided in subsections (3) and (5) of this section, a health insurer may not: (a) Request from a health care provider a refund of a payment previously made to satisfy a claim unless the health insurer: (A) Requests the refund in writing within 24 months after the date the payment was made; and ( Specifies in the written request why the health insurer believes the provider owes the refund. ( Request that a contested refund be paid earlier than six months after the health care provider receives the request. (3) A health insurer may not do the following for reasons related to coordination of benefits with another health insurer or entity responsible for payment of a claim: (a) Request from a health care provider a refund of a payment previously made to satisfy a claim unless the health insurer: (A) Requests the refund in writing within 30 months after the date the payment was made; ( Specifies in the written request why the health insurer believes the provider owes the refund; and © Includes in the written request the name and mailing address of the other health insurer or entity that has primary responsibility for payment of the claim. ( Request that a contested refund be paid earlier than six months after the provider receives the request. (4) If a health care provider fails to contest a refund request in writing to the health insurer within 30 days after receiving the request, the request is deemed accepted and the provider must pay the refund within 30 days after the request is deemed accepted. If the provider has not paid the refund within 30 days after the request is deemed accepted, the health insurer may recover the amount through an offset to a future claim. (5) A health insurer may at any time request from a health care provider a refund of a payment previously made to satisfy a claim if: (a) A third party, including a government entity, is found responsible for satisfaction of the claim as a consequence of liability imposed by law; and ( The health insurer is unable to recover directly from the third party because the third party has already paid or will pay the provider for the health care services covered by the claim. (6) If a contract between a health insurer and a health care provider conflicts with this section, the provisions of this section prevail. However, nothing in this section prohibits a health care provider from choosing at any time to refund to a health insurer any payment previously made to satisfy a claim. (7) This section neither permits nor precludes a health insurer from recovering from a subscriber, enrollee or beneficiary any amounts paid to a health care provider for benefits to which the subscriber, enrollee or beneficiary was not entitled under the terms and conditions of the health plan, insurance policy or other benefit agreement. (8) This section does not apply to claims for health care services provided through dental-only health insurers, through Medicare or through Medicare supplemental plans. [2009 c.807 §2]” T. Hill, PC520 SW Sixth Avenue, Suite 1250Portland, OR  97204(503) 227-4330chill@...http://www.portlandinjurylaw.com From: [mailto: ] On Behalf Of Don Sent: Tuesday, January 18, 2011 1:22 PMbluepearl2001@...; Subject: RE: Insurance Refund Request I don’t know about the “rule” but if the policy was expired and they paid a benefit by accident, the RIGHT thing to do is give the ins. company their money back. You’ll notice that benefits explanations quoted over the phone almost always include the caveat that “this is not a guarantee of payment”. They know how to cover their arses. Don Corvallis From: [mailto: ] On Behalf Of bluepearl2001@...Sent: Tuesday, January 18, 2011 12:07 PM Subject: Insurance Refund Request Greetings.What is the " RULE " , if there is one, for refunding insurance companies. I was paid for 3 treatments, then subsequently found out that the insurance had expired and will be asked for a refund. So their payment was a mistake on their end.BTW-They also told us that the patient's coverage went thru the end of the year... And they were wrong about that, too.Am I required to refund??Just asking...Ann DC

[Guest guest]

If you are a preferred provider it likely is in your contract that you must refund, otherwise the ins. Co may take it out of reimbursement for other patients. Blue cross loves to do this. SwansonSent from my iPhoneOn Jan 18, 2011, at 1:53 PM, " Hill" <chill@...> wrote:

Well, they are a professional insurance company in the business of evaluating and paying/denying claims. If they had all the relevant facts, IMO they should be regarded as waiving the right to reimbursement. However, the 2009 legislature passed a law dealing with the issue, codified at ORS 743.912, which probably trumps any waiver arguments: “743.912 Refund of paid claims. (1) As used in this section, “refund†means the return, either directly or through an offset to a future claim, of some or all of a payment already received by a health care provider. (2) Except in the case of fraud or abuse of billing, and except as provided in subsections (3) and (5) of this section, a health insurer may not: (a) Request from a health care provider a refund of a payment previously made to satisfy a claim unless the health insurer: (A) Requests the refund in writing within 24 months after the date the payment was made; and ( Specifies in the written request why the health insurer believes the provider owes the refund. ( Request that a contested refund be paid earlier than six months after the health care provider receives the request. (3) A health insurer may not do the following for reasons related to coordination of benefits with another health insurer or entity responsible for payment of a claim: (a) Request from a health care provider a refund of a payment previously made to satisfy a claim unless the health insurer: (A) Requests the refund in writing within 30 months after the date the payment was made; ( Specifies in the written request why the health insurer believes the provider owes the refund; and © Includes in the written request the name and mailing address of the other health insurer or entity that has primary responsibility for payment of the claim. ( Request that a contested refund be paid earlier than six months after the provider receives the request. (4) If a health care provider fails to contest a refund request in writing to the health insurer within 30 days after receiving the request, the request is deemed accepted and the provider must pay the refund within 30 days after the request is deemed accepted. If the provider has not paid the refund within 30 days after the request is deemed accepted, the health insurer may recover the amount through an offset to a future claim. (5) A health insurer may at any time request from a health care provider a refund of a payment previously made to satisfy a claim if: (a) A third party, including a government entity, is found responsible for satisfaction of the claim as a consequence of liability imposed by law; and ( The health insurer is unable to recover directly from the third party because the third party has already paid or will pay the provider for the health care services covered by the claim. (6) If a contract between a health insurer and a health care provider conflicts with this section, the provisions of this section prevail. However, nothing in this section prohibits a health care provider from choosing at any time to refund to a health insurer any payment previously made to satisfy a claim. (7) This section neither permits nor precludes a health insurer from recovering from a subscriber, enrollee or beneficiary any amounts paid to a health care provider for benefits to which the subscriber, enrollee or beneficiary was not entitled under the terms and conditions of the health plan, insurance policy or other benefit agreement. (8) This section does not apply to claims for health care services provided through dental-only health insurers, through Medicare or through Medicare supplemental plans. [2009 c.807 §2]†T. Hill, PC520 SW Sixth Avenue, Suite 1250Portland, OR 97204(503) 227-4330chill@...http://www.portlandinjurylaw.com From: [mailto: ] On Behalf Of Don Sent: Tuesday, January 18, 2011 1:22 PMbluepearl2001@...; Subject: RE: Insurance Refund Request I don’t know about the “rule†but if the policy was expired and they paid a benefit by accident, the RIGHT thing to do is give the ins. company their money back. You’ll notice that benefits explanations quoted over the phone almost always include the caveat that “this is not a guarantee of paymentâ€. They know how to cover their arses. Don Corvallis From: [mailto: ] On Behalf Of bluepearl2001@...Sent: Tuesday, January 18, 2011 12:07 PM Subject: Insurance Refund Request Greetings.What is the "RULE", if there is one, for refunding insurance companies. I was paid for 3 treatments, then subsequently found out that the insurance had expired and will be asked for a refund. So their payment was a mistake on their end.BTW-They also told us that the patient's coverage went thru the end of the year... And they were wrong about that, too.Am I required to refund??Just asking...Ann DC

[Guest guest]

WOW. thanks. very thorough and helpful. You're a great asset to this list.

Minga Guerrero DC

Insurance Refund Request

Greetings.

What is the "RULE", if there is one, for refunding insurance companies. I was paid for 3 treatments, then subsequently found out that the insurance had expired and will be asked for a refund. So their payment was a mistake on their end.

BTW-They also told us that the patient's coverage went thru the end of the year... And they were wrong about that, too.

Am I required to refund??

Just asking...

Ann DC

[Guest guest]

So is correct?

In my patient's case, she thought her coverage was null and void because she was in arrears with her Cobra payment. But she seemed confused about how her insurance was structured.

So we called to check and was told that she had an full year of coverage on a yearly plan (NOT a month to month Cobra) and that her coverage went though the end of December. So with that information (including the name of the insurance guy and a reference number for the call), we informed the the patient and she continued her care.

Then we received a denial based on terminated coverage after the fact. When we called back, Regence said that at the time of the insurance verification call from our office, they had not 'updated' their computers and further, that my office manager should have asked if the plan was a yearly or month to month plan as a follow up question. My office manager responded by asked, "WHY would I ask if it was a month to month after I had been told that it was a yearly plan?"

Anyway, you get the gist. The problem with this is that the patient continued with care that she could not afford and had we not told her that she was good to go through December, she would have made a different decision. She's unemployed... Now we get to be the stinkers and have her pay, though I will offer to reduce her bill.

AND I get to refund some of the previous payments Regence mistakenly made on her behalf. Ouch again for the patient who will be billed for that amount.

Ann DC

Insurance Refund Request

Greetings.

What is the "RULE", if there is one, for refunding insurance companies. I was paid for 3 treatments, then subsequently found out that the insurance had expired and will be asked for a refund. So their payment was a mistake on their end.

BTW-They also told us that the patient's coverage went thru the end of the year... And they were wrong about that, too.

Am I required to refund??

Just asking...

Ann DC