Corporate Compliance

Tip: Watch out for overpayments

Compliance Monitor, December 19, 2007

Fielding requests for overpayment refunds is unfortunately an all-too-familiar scenario for most providers. Here are the top three scenarios that trigger refund requests:

  • Primary versus secondary insurance. Situations in which there is primary and secondary insurance often lead to overpayment issues. The secondary insurance pays the provider for the entire amount of the claim, thinking it's the primary insurance, then comes back months later asking for a refund. It is beneficial to have clear procedures with specific contacts in your office to handle overpayment refund requests.
  • Retroactive disenrollment. A plan might not be diligent enough about keeping track of the list of eligible employees. Go through the enrollment list that the plan had so you can determine whether you had the most up-to-date information, or if the plan failed to update you. This will help avoid putting yourself in a vulnerable position.
  • Medical necessity. A third type of overpayment occurs when plans determine that services rendered were not medically necessary or appropriate. Remember to always establish clear ground rules for reopening medical management decisions.

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