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Adjustments of Previously Paid Claims

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Thursday, October 12, 2017

I was recently contact by an OPA member who was encountering a difficult situation with an insurance company.  He received notice from the company in question stating a prior reimbursement they made was invalid, and they were therefore asking for the payment to be returned.  The initial payment had been made more than two years prior to the date the determination notice had been sent.  The psychologist contacted me about the legitimacy of this determination and request.  Like so many of us, he vaguely recalled there are limits to such “take back” requests, but he was unsure of the specifics.  (Apparently the insurance company making this determination was somewhat lacking in understanding, also). 

I reminded him of Ohio law on this topic, which I am copying below.  Insurance companies may look back and make a new determination about previously paid claims, but they are limited to a two-year period.  In other words, a request for return of paid claims is limited to the two-year period immediately preceding the notice requesting the return of funds.  The following is taken from the Ohio Department of Insurance website:

Adjustments of Previously Paid Claims

Claim payments that are made on or after July 24, 2002, are deemed final two years after the payment is made. After that date, the amount of the payment is not subject to adjustment, except in the case of fraud by the provider. 
 
A third-party payer may recover the amount of any part of a payment that the third-party payer determines to be an over-payment if the recovery process is initiated not later than two years after the payment was made to the provider. 
Upon determination of an over-payment a third-party payer shall send a notice to the provider that contains the following:

  1. The full name of the beneficiary who received the health care services for which over-payment was made;
  2. The date or dates the services were provided;
  3. The amount of the over-payment;
  4. The claim number or other pertinent numbers;
  5. A detailed explanation of basis for the third-party payer's determination of over-payment;
  6. The method in which payment was made, including, for tracking purposes, the date of payment and, if applicable, the check number;
  7. That the provider may appeal the third-party payer's determination of over-payment, if the provider responds to the notice within thirty (30) days;
  8. The method by which recovery of the over-payment would be made, if recovery proceeds under division (B) of this section.

Please note number seven above which allows for an appeal of the re-determination.  I urged the psychologist who reached out to me to appeal the adjustment determination, including a copy of the above information.

I hope you find this reminder helpful.  Please feel free to let me know whether you have encountered similar difficulties and about any problems you had responding to such requests.  

Jim Broyles, PhD
OPA Director of Professional Affairs

 

 

 

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