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Why is money subtracted on my explanation of benefits?

May 17, 2016



Money looks like its being subtracted from my explanation of benefits.  Can a third party payor keep my money? I had some claims denied after payment. Thoughts?

Dr. P


Dr. P, looks like you may be a victim of an "offset". Offsetting is a common tool (more so recently) of third party payors where they take money from payable claims to reimburse themselves for "non-payable" claims. "Non-payable" in their determination, not necessarily yours or the objective perspective's. Offset as a tool is supported by case law and also may be a tactic you have authorized by contract. That's right! You may have agreed to allow the payor to use offset. This language is a fairly new addition to payor contracts.  I've seen it added mostly in the last 2-3 years, normally hidden 2/3s of the way through (way after you've stopped reading). I know the next question you may have, which is - Jennifer, how can they get away with this?  Well, I've just explained the foundation the payor has laid for itself authorizing offsetting, the real question is what can you do about it? The answer to that is a little more involved, and depends on individual circumstances. But, I do recommend you do not accept offsetting sitting down.  Payors will just keep nibbling until there is nothing left... 


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