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Insurer Error, Refund Required?

April 15, 2014


Question:

Hi, Jennifer-
 We have a patient who we see on a weekly basis who is covered by a United Medicare Advantage plan. Although we have always participated with this plan, a change occurred about a year ago during which they increased the reimbursement amount. This continued for some time, and then we were asked to refund the difference between the previous payment amounts and the new amounts for each claim. When we inquired about this request, we discovered that we had been paid during that time at the rate used for an out-of-network provider (which is actually $11-$15 MORE per claim than the in-network amount).
We have repeatedly contacted United regarding this, with no satisfactory resolution. Since we never changed our participating provider status and they paid these claims directly to us (which would also indicate participating status- if we were non-par they would have sent checks to the subscriber, I think), are we obliged to refund this money? They made the error through no fault of ours and then decided to request a refund for each of these erroneously paid amounts.
Please advise us as to how we should proceed..

Regards,
MC

Answer:

Good question, and one of the tougher to swallow.... I would start a review and take a look at whether there were any communications between United and the practice indicating a rate change or authorizing a rate change.  Here, it seems no such notice was received, the money just started coming in at a higher rate.  Also evident, in our scenario, United is merely the administrator of the Medicare Advantage plan, and as such the fee schedule would presumably have been available.  Especially as the payment received is based from Medicare funds, you will likely be unable to negotiate or mitigate the amount owed upon return.  Some of my colleagues would potentially suggest taking an aggressive stance, potentially citing ERISA as precedent, that the funds having been commingled with practice recoupment can no longer be identified for recoupment.  I am not sure I believe that to be a winning argument.  What you may risk by not complying with a recoupment request is set-off or issues with payment of pending claims, which could damage your practice.   One way to handle this situation is for your attorney to make a few inquiries and try to get further up the food chain to resolve, possibly settle for less than 100 cents on the dollar (although, this result is unlikely).  I never like to advise spending good money chasing bad; here you will likely be making the best decision by refunding on your own accord.  Of course now that you see the reimbursement, you may wish to switch to out of network. 
 

HBMA Members - remember, your discount on all compliance documents expires on April 18, 2014!!!!

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Recommendation on discarding Controlled Substances - (Thank you to Cheryl Malone, always an incredible resource! #supportoursocieties!)

Hi, Jennifer:
 
Hope all is well with you.  I wanted to share this resource with your  after reading today’s Healthcare Newsletter on controlled substance storage.  Dispensary of Hope is an organization that  doctors can use to help with  medication samples disposal. 
 
 Dispensary of Hope is a nonprofit organization that helps doctors donate sample or shortly expiring medications so they can be used by clinics serving the needy.  (They will take expired medication as well for disposal.)    Not only do they  put medications in the hands of a patient in need, they also reduce their staff time, reduce medical waste, and help the community.   Pledge to donate sample medications and the Dispensary of Hope will provide the practice with a donation bin and prepaid shipping. Participation is free.  The New York County Medical Society’s Clifford L. Spingarn, MD Memorial  Education Fund (aka MEDCOFUND) is a supporter of  Dispensary of Hope.    New York County Medical Society members have donated over $400,000 worth of medication in the past two years.  The practice will receive an itemized receipt of the samples donated for  its records.  No more worry about disposal or waste, and itemized list of what was donated.  Doctors can pledge today  at www.dispensaryofhope.org/give-meds  
 
Cheryl
 
Cheryl M. Malone, CAE
Executive Director
New York County Medical Society
12 East 41 Street, 15th Floor
New York, NY 10017
(212) 684-4670, ext. 210
Fax: (212) 684-4741
www.nycms.org

     
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