Managing Takebacks and Coordination of Benefits

June 1, 2008

I provided care to an elderly man and was reimbursed by our area Blues plan. The man had applied for and was eventually granted Social Security Disability and with that Medicare retroactively became the primary payer for the claims for which I’d already been paid. The Blues plan then demanded repayment from us. We paid them. Then we filed claims for these services with Medicare explaining in great detail with a copy of the explanation we’d received from Blue Cross the reason why we were past the 90-day limit in filing. Medicare denied the claims anyway on the basis of lack of timeliness without comment on our explanation. What am I supposed to do?

Question: I provided care to an elderly man and was reimbursed by our area Blues plan. The man had applied for and was eventually granted Social Security Disability and with that Medicare retroactively became the primary payer for the claims for which I’d already been paid. The Blues plan then demanded repayment from us. We paid them. Then we filed claims for these services with Medicare explaining in great detail with a copy of the explanation we’d received from Blue Cross the reason why we were past the 90-day limit in filing. Medicare denied the claims anyway on the basis of lack of timeliness without comment on our explanation. What am I supposed to do?

Answer: Here’s how it would have gone, ideally:

The insurance company asks for the money back. You respond within 30 days to say “Okay, we’ll submit to Medicare and get back to you.”

Medicare denies the claim.

You send the denial to the insurance company.

The insurance company settles or sends the patient a notification that they won’t pay and then you bill the patient.

In other words, you should not have repaid the Blues plan before going to Medicare. This may help in the future.

On this claim, for now, the only thing you can do is bill the patient along with a letter asking the patient to appeal Medicare’s denial. This will help, and hopefully allow for Medicare to overturn the “timely filing” issue. That is, it isn’t a timely filing issue, it is a coverage of benefit issue, and Medicare would rather fix the claim than penalize the patient. But, until the patient gets involved, it’s all too easy for the payers to keep denying.

Thanks to Susanne Madden, The Verden Group, for this answer.