Controlling Payer Refund Requests

June 1, 2009

I just got a refund request from a payer. It’s for close to $1,000 for a patient we saw from 2004 to 2007. The payer now says the patient wasn’t eligible then. We checked, and it turns out the patient actually was on a Medicaid managed care plan and was not with the payer we billed. Still, Medicaid won’t consider claims from 2004. I just do not know what my options are. Are there any regulations to prevent this?

Question: I just got a refund request from a payer. It’s for close to $1,000 for a patient we saw from 2004 to 2007. The payer now says the patient wasn’t eligible then. We checked, and it turns out the patient actually was on a Medicaid managed care plan and was not with the payer we billed. Still, Medicaid won’t consider claims from 2004. I just do not know what my options are. Are there any regulations to prevent this?

Answer: Typically, your contract with your payers defines how far back they can go for refunds. This, by the way, is an issue you can sometimes negotiate at renewal time. Check your contract. If it sets a long period or doesn’t define anything, you may have no recourse. You can take a look at whether your state Medicaid will accept the later claims to recoup at least some of the money. Of course, the real lesson learned here is to look for ways to tighten up your pre-registration and authorization to avoid as many of these sorts of mistakes as possible.