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Payor mistake, can I keep cash?

           June 25, 2015
 
Question:

Hi Jennifer,

An insurance carrier openly admits that they incorrectly reimbursed and overpaid claims due their own error. They state "claims were incorrectly reimbursed due to an incorrect contract configuration of incorrect rates, fee schedules, and percentage of reimbursements."

Is it clear that the carrier is at fault?   Can I keep the money?

Thanks, Dr. N

Answer:
 
Yikes!  Sounds convoluted and difficult to track.  The issue here is if you participate you have contractually agreed to accept the contractually set rate.  If the carrier can prove the rate was inflated by error, you will likely be hard pressed to prove your case in keeping the cash.  If the carrier is backtracking off of monies paid without substantiation for a "necessary" adjustment, absolutely I would fight tooth and nail.  A major consideration I do not have clarity on is how long ago the claims were paid the adjustment is applicable to.  

To offer a specific opinion on what stance you should take, we'd have to take the conversation offline and i would need more information. 

Thanks for the question!
 
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