Steve Verno
Global Moderator
Hero Member
Kudos: +203/-0
 Offline
Gender: 
Posts: 1573
|
 |
« Reply #1 on: January 22, 2009, 03:56:56 AM » |
|
Depends on your State law requirements.
If the benefit is under ERISA jurisdiction, State Law may not have jurisdiction. One HMO demanded a refund years after paying. We denied using Florida Law. The HMO came back and said the plan was an ERISA Plan. We denied because ERISA has no refund issues listed. We referred the HMO to the patient for the refund.
Here in Florida refunds are discussed in FS 627.6131 and 641.3155. The wording is the same in both. The following is from 641.3155.
The 2008 Florida Statutes
Title XXXVII
INSURANCE Chapter 641
HEALTH CARE SERVICE PROGRAMS
641.3155 Prompt payment of claims.--
(5) If a health maintenance organization determines that it has made an overpayment to a provider for services rendered to a subscriber, the health maintenance organization must make a claim for such overpayment to the provider's designated location. A health maintenance organization that makes a claim for overpayment to a provider under this section shall give the provider a written or electronic statement specifying the basis for the retroactive denial or payment adjustment. The health maintenance organization must identify the claim or claims, or overpayment claim portion thereof, for which a claim for overpayment is submitted.
(a) If an overpayment determination is the result of retroactive review or audit of coverage decisions or payment levels not related to fraud, a health maintenance organization shall adhere to the following procedures:
1. All claims for overpayment must be submitted to a provider within 30 months after the health maintenance organization's payment of the claim. A provider must pay, deny, or contest the health maintenance organization's claim for overpayment within 40 days after the receipt of the claim. All contested claims for overpayment must be paid or denied within 120 days after receipt of the claim. Failure to pay or deny overpayment and claim within 140 days after receipt creates an uncontestable obligation to pay the claim.
2. A provider that denies or contests a health maintenance organization's claim for overpayment or any portion of a claim shall notify the organization, in writing, within 35 days after the provider receives the claim that the claim for overpayment is contested or denied. The notice that the claim for overpayment is denied or contested must identify the contested portion of the claim and the specific reason for contesting or denying the claim and, if contested, must include a request for additional information. If the organization submits additional information, the organization must, within 35 days after receipt of the request, mail or electronically transfer the information to the provider. The provider shall pay or deny the claim for overpayment within 45 days after receipt of the information. The notice is considered made on the date the notice is mailed or electronically transferred by the provider.
3. The health maintenance organization may not reduce payment to the provider for other services unless the provider agrees to the reduction in writing or fails to respond to the health maintenance organization's overpayment claim as required by this paragraph.
I looked at a State of Texas Guide I created and this is what I found regarding overpayments:
§ 843.350. OVERPAYMENT.
(a) A health maintenance organization may recover an overpayment to a physician or provider
if:
(1) not later than the 180th day after the date the physician or provider receives the payment, the health maintenance organization provides written notice of the overpayment to the physician or provider that includes the basis and specific reasons for the request for recovery of funds; and
(2) the physician or provider does not make arrangements for repayment of the requested funds on or before the 45th day after the date the physician or provider receives the
notice.
(b) If a physician or provider disagrees with a request for recovery of an overpayment, the health maintenance organization shall provide the physician or provider with an opportunity to appeal, and the health maintenance organization may not recover the overpayment until all appeal rights are exhausted.
Me. As a biller, if the claim was more than the 180 days as listed above, I would have denied their claim and instructed them they could not take payments from a claim in their possession.
|
