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Know Your Rights When Insurance Co. Asks for Money Back


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Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  Due to the unique language of acupuncture, there will be errors, so we suggest you watch the video while reading the transcript.

Hi everyone. Welcome to another episode with the American Acupuncture Council. I’m Sam Collins, the coding and billing expert for acupuncture, the American Acupuncture Council, as well as the profession in general. This episode is gonna deal with a very common question that I get whenever I’m teaching a seminar or doing our network services.

People always ask, Hey, Sam, I got a payment. Now the insurance company is asking for money. What can I do? Is there anything I can do to fight this back? What if they recoup the money? There are many things you can do, and there’s laws and statutes that are on your side. Never assume what they tell you is correct.

Let’s face it, you do an insurance verification, you bill the insurance, they pay it, and then they come back later and say, Hey, we paid you money six months ago. Turns out we shouldn’t have. So let’s take a scenario like that. The insurance company pay. . Then they come back and say, Oops, we shouldn’t have paid because there were visits that were applied towards the whole overall benefit.

Maybe it’s combined with chiropractic, maybe with physical therapy, and now they want it back. What are our rights? What do we do? So let’s go to the slides. Let’s talk about what laws and things protect you in understanding how we have to deal with this. This is not uncommon. Now, I don’t want this to scare you off.

This doesn’t happen a lot, but it happens enough. You have to know what your rights. What are my rights when someone says, We shouldn’t have paid you and we want this back? So here’s a letter and please note everyone, this is a letter from Federal Blue Cross Blue Shield and notice what it’s saying. Dear Billing Department, they’re talking to us directly in regards to the request for repayment for claim.

The request made to you was a voluntary overpayment request. Because you are in network provider, you do not have to pay back any overpayment if the overpayment was discovered 365 days or more after the claim was finalized. So I wanna take a look at this letter and notice what they’re stating here.

They’re stating that they can request an overpayment if you are in network, but not if it’s over 365 days. So notice that’s why the letter says a voluntary overpayment realize most often when an insurance company is requesting a re. they’re doing. So just to see if you’re willing to pay it. So by example, let’s say a policy, as I mentioned, has 20 visits per year.

You verify it and they pay it, and then later they come back six months later, a year later and say, Oops, it turns out the patient already had visits with some other provider. Therefore, we shouldn’t have paid you. Frankly, whose fault is that? You did the proper verification, you bill it, they paid it.

Now they’re saying, Oops, we made a mistake. We want you to pay it back. So notice that’s why this says voluntary. So even though this provider is in network, they’re saying please pay us back. My issue is gonna be no thanks. Why should I pay you back if it’s your mistake? In essence, what they’re saying is, we made a.

And the patient’s benefits weren’t there. Therefore, we want you to pay back our mistake. My rule would be, no, you go to your insured, That’s who you made the mistake with. Cuz essentially what they’re trying to push you to do is you pay them back and now go after the patient. Why would we have to go after the patient if that’s your insured?

That’s where you’ll notice the difference here. Notice it says here, the request made to you was volunt. And because you are in network and it’s over 365 days. So notice now the difference if they had done this within 365 days because you’re in network, they can take it back. This is one of the downsides of belonging to an insurance you give them to right to recoup.

Even when the error wasn’t yours. It was their own mistake. So it’s one of the downsides of being in network. Now, if you were out of network, could you just completely refuse this and say, Actually you could in the absence of fraud, where something you build wrong or maybe they paid you twice, you are under no obligation to refund this.

I’m gonna point you to this is a letter that we use for those in our network, or those that come to a seminar that deals with an insurance company that has paid you and then subsequently wants it back. So notice at the top it says, We received your letter where your company’s requesting re refund the payment, and you reviewed the benefits and nothing here shows otherwise.

So let’s move down here. It says, I feel that you have do not have the right to place this burden upon my office by asking us to correct your error. And this is backed up by Case Law. Notice it says, I would like to bring your attention to cases involving the Federated Mutual Insurance Company, and essentially it says the insurance company is in the best position to know the policy limits and must bear the responsibility of their own mistake.

So again, if you’re out of network and the insurance is asking for this back, understand if they made the mistake and paid more than they should. Maybe there was a deductible, they didn’t apply or they just applied more visits than the plan allows. They have to bear the responsibility for it. And again, case law noting dating back to 1974, so for many of you may not have even been born yet.

The next case goes from here for national Western Life Insurance Company. And it says in the absence of. A healthcare provider is not legally obligated to run refund payments. It receives from an insurer if the insurer subsequently determines they were paid in error. So let’s do this example. You call, the plan says they cover acupuncture.

Great. You bill it, they pay it, and then six months later they say, Oops, it turns out we don’t cover acupuncture. Whose fault is that? You did everything properly. What they’re saying is, pay us back and you chase the patient. My rule would be, You go after your own patient. That’s why that one said voluntary.

You’re under no obligation to pay this. So when you were out of network, , you may completely push back on this with citing these two case laws, because if there’s nothing wrong with the claim, you didn’t bill anything in error. There wasn’t something billed that you didn’t provide, or they didn’t pay you twice.

If someone pays you twice for the same data service, you do have to refund the overpayment of that. But outside of that, the answer is absolutely no. Again, if you’re out of network. Now, why is it different if you’re in. It’s different when you’re in network because part of the contract we sign, when we join these insurances, it literally says in the contract, Should we make an overpayment?

Even if the error was on our side, we can recoup the money. And I’m sure many of you, almost Sam, that’s happened to me before. They just take the money from another patient. They will if you’re in network. If you’re out of network, they should not be because they have no right to that. In fact, the case law stands up, but let’s talk about if you’re in network.

Notice it said one year. Now that’s the federal statute, which is generally equal to what the billing time is. So if the billing time is one year, they have one year to recoup again, if you’re in network. So if you are in network, they can recoup. Within the timeframe of the statute of limitations, and that’s where this is a little bit different from state to state.

So I’m gonna give you a little breakdown here. This has every state, and you’ll notice it can vary from some, That’s one year, 36 months, five years, two years, all the way down to as little as 30 days for some. And some states don’t have any, which to me means it defaults to the federal statute. But always know the statute of limitations.

Just like an insurance. You know how some insurances are? You have 30 days to bill 60, 90, or one. The same thing applies here for a recoupment. The state law will break it down. So is it one year or otherwise? So know your state and whether or not you can push back. My rule would be always send a letter like this in a response when you are out of network.

Even in network, I would use the same protocols, but then follow up with the statute of limitations. Do not be. To push back. The assumption is often you don’t know better and are just gonna pay, cuz we’re afraid of the insurance we’re gonna get in trouble. If they could recoup it in network, they probably would’ve.

So take a look here. Here’s an Aetna claim, and notice what it says As a result of a routine claims payment, we previously notified you that there were some differences between the amount paid and the amount, which you should have been. That’s their own issue. So notice and I highlighted it in yellow, it says, Our records indicate the overpayment as noted on the enclosed document, is not eligible to be offset from future claim payments.

In other words, you’re outta network. So we can’t force you to pay it back, but we’re gonna please say therefore we must request you issue a check or money order payable to us in the amount that’s requested. You know what my answer to that is? No thank. Why would I voluntarily send it? When do they ever voluntarily say, Hey, you know what?

We’re not paying you enough. We’re just gonna go ahead and pay you more. Know your rights. Don’t be afraid to push back when there’s a request for overpayment. Was it truly overpaid? Did they pay you more than you billed? That you would’ve to pay back the amount over what you build? Or if they paid you twice.

But if you’re out of network and they later decide, they didn’t feel they should have paid it too. That’s on them. They should know their own policy. And the Statue of limitation applies for those of you who are in network, just like they put a limit to the time that you can send a. They will have limits to when they recoup.

This is why a lot of providers think maybe I don’t want to be in network, cuz I give them a little bit of power that’s part of that tradeoff. We did this in an earlier talk with you of trading off what is it worth it or not. Now this doesn’t happen enough to where it’s gonna major problem, but it’s something to note within your rights because many times they’ll just send you a letter hoping you’ll pay.

Let’s say you send a hundred of these letters out, maybe 50 of the doctors know the rule. They’re not gonna pay it, but the other 50. That’s an easy way for them to recoup money by simply having people not aware of what their rights are. Notice. These plans aren’t necessarily there for you. Always be able to push back and know where the laws fit.

That’s what we’re here to do. That’s what the American Acupuncture Council is there to do. We always wanna enhance your practice as I do. For those of you who would want to have help, just what we’re doing now where we can deal with this one-on-one via phone or Zoom or otherwise, you may wanna join our network.

Take a look at our site. You can do the QR code or go directly to our site. Remember, it’s aac info We’re always here. The American Acupuncture is always going to be your resource, your place for help. And remember, first of the year is coming. What’s gonna be changing, lots of things, codes, fees, and otherwise probably time to get to a continuing education seminar with the American Acupuncture Council Network.

I hope to see all of the future date. Until then, best wishes everyone.