ITS NOT OVER AFTER CLAIMS ARE PAID
We have seen a surge of refund requests from many insurance companies. These are coming to us from one month after the claim is paid to almost 2 years after the claim has been settled. These refund requests have gotten more frequent now with the economic downturn. If you pay close attention you will see that most come from third party companies. These companies pitch the potential recovery estimates to insurance companies and in turn their profit at collecting such funds. We cant say that the refund requests are illegitimate, but the fact that they survive on scavenging settled claims is a bit appalling.
The main issue we have with this practice is when they refer to claims beyond their own timely filing deadlines. Yes they will not pay a claim past 90 days of the date of service but they will ask for money beyond 18 months of the payment date. Sounds unfair, no? We have asked the insurance and those that know about contracts how to counter act these requests and there is no particular recourse. There are obviously, legal means by which to deal with these if they are unfounded or unfair, but they are quite time consuming and cumbersome.
Many of these refunds requests are due to patient data not correctly set at the insurance end once the claim has been processed. Our office prides itself on obtaining as much detailed and up to date information on our patients policies, hence avoiding surprises for us and for our patients. None the less this is not enough for that 10 to 15% of the claims (probably less, but the work related to resolution feels like much more). We have had the case where the policy has been terminated as of one date say January of 2008, but our patient came to us on July. Even on July at the time of service our staff has verified (obtaining reference numbers and or printouts from the insurance website) eligibility as active and now then the refund request comes to us indicating the policy terminated on January of the same year, that’s about 6 months worth of outdated information!
Now with such a lag on information updates from employers to insurance or from insurance group to another, who are we to trust for payment of our patent’s claims? Now then, they make the provider responsible for this by requesting a refund. As a matter of principle, the employers or even the insurance should own up to their belated actions and carry the financial responsibility of not keeping records up to date. That is just an opinion of course. Without such, they have NO incentive whatsoever to keep their records straight.
The third party collection agencies use quite a bit of aggressive means to collect these funds. It doesn’t matter how cumbersome it is to deal with them, providers should be careful to investigate each case for its validity and deal with each appropriately. If you have done your homework on those and believe the request is belated or unfounded, then use what resources you have to dispute it, including the information obtained while verifying the policies involved, or medical information if its related to “INCORRECT” processing. Don’t give in too easily.