Guest guest Posted June 7, 2011 Report Share Posted June 7, 2011 I would love to see UHC's response to Selena's response. I don't know what the laws are in MS, but here in Arkansas insurance companies can request recoupment for up to 18 months after the services were rendered. This has caused great frustrations for our pediatric providers as Medicaid has a 12 month timely filing requirement so when ABC Insurance company later determines that claims were paid that should not have been and request their money back 14 months later, the provider ends up with no payment. The parent's can't pay that is why their children are eligible for Medicaid to begin with. Medicaid won't pay because it was not timely filed and ABC washes their hands of it. We proposed a bill a few years back to lower this to 6 months to allow providers to refile if necessary, however BCBS asked us to pull the bill and agreed to work with our provider on a solution. I am not sure this went much further after that but I don't think they have been waiting as long on Medicaid claims to audit them. Becky A. Sewell, MRC, CRC Rehab Net of AR/ArPTA P.O. Box 202 Conway, AR 72033 ph/fax _____ From: PTManager [mailto:PTManager ] On Behalf Of selenahorner Sent: Monday, June 06, 2011 9:30 PM To: PTManager Subject: Re: UHC overpayment Doug, I'll disagree with Jim... I have a much better response. Just send a quick little note indicating that you received UHC request and appreciate UHC believes UHC made an error. Politely inform UHC that PT Center of Ocean Springs is not enrolled in UHC nor a network provider for UHC. Verify to UHC that you analyzed the account in question and PT Center of Ocean Springs does not note any account overpayments. Communicate that if UHC believes an overpayment occurred on UHC behalf, UHC only has a contractual agreement with the subscriber. Suggest UHC contact the subscriber for the overpayment error. Selena Horner, PT ton, MI > > > > > Personally I would have a difficult time trying to respond to this letter with any words that are larger than four letters. > > Of course sometimes when I am in a better mood, my thought process is on the high road and I write a response along the lines of: > > " we have a company policy that states all overpayment requests must be made by certified mail, written in swahili and must be received within 90 days of your original payment. " Unfortunately, your request exceeded our policy and therefore, you have exceeded the statute of limitations for requesting a refund. If you believe our policy is unfair, you can make an appeal to the Reimbursement Chair of the Clinic, and they will review your request within 180 days and get back to you. Should you decide that you want to explore this avenue, you will need to submit a page for each CPT code that you feel you paid inappropriately, clearly indicating the patient's name, our account number, the amount we charged, what you actually paid us and how much you feel you overpaid along with a written description from your Medical Director on the validity of the medical necessity of the overpayment refund request. Blah, blah, blah and so forth. Also, make sure your envelope is hermetically sealed..., as failure to do so could make you forfeit your right to this refund. > > Oh..., and good luck, we will be in touch. > > Sorry, sometimes I just write these things for my own amusement, but I hope you find a policy worth implementing somewhere in this email! > > Jim <///>< > > > > > > > UHC overpayment > > > > > Group. > > We are an out of network provider for United Health Care. > > Patients were seen over 12 months ago. UHC is now requesting partial reimbursement for services rendered and paid for at this clinic. Hard to believe, reason stated, they overpaid for services. > > Have any of you had similar requests? > > Did you respond? > > Is there a statute of limitations on such requests? > > Roll > PT Center of Ocean Springs > Ocean Springs, MS > www.ptcos.com > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 7, 2011 Report Share Posted June 7, 2011 I would love to see UHC's response to Selena's response. I don't know what the laws are in MS, but here in Arkansas insurance companies can request recoupment for up to 18 months after the services were rendered. This has caused great frustrations for our pediatric providers as Medicaid has a 12 month timely filing requirement so when ABC Insurance company later determines that claims were paid that should not have been and request their money back 14 months later, the provider ends up with no payment. The parent's can't pay that is why their children are eligible for Medicaid to begin with. Medicaid won't pay because it was not timely filed and ABC washes their hands of it. We proposed a bill a few years back to lower this to 6 months to allow providers to refile if necessary, however BCBS asked us to pull the bill and agreed to work with our provider on a solution. I am not sure this went much further after that but I don't think they have been waiting as long on Medicaid claims to audit them. Becky A. Sewell, MRC, CRC Rehab Net of AR/ArPTA P.O. Box 202 Conway, AR 72033 ph/fax _____ From: PTManager [mailto:PTManager ] On Behalf Of selenahorner Sent: Monday, June 06, 2011 9:30 PM To: PTManager Subject: Re: UHC overpayment Doug, I'll disagree with Jim... I have a much better response. Just send a quick little note indicating that you received UHC request and appreciate UHC believes UHC made an error. Politely inform UHC that PT Center of Ocean Springs is not enrolled in UHC nor a network provider for UHC. Verify to UHC that you analyzed the account in question and PT Center of Ocean Springs does not note any account overpayments. Communicate that if UHC believes an overpayment occurred on UHC behalf, UHC only has a contractual agreement with the subscriber. Suggest UHC contact the subscriber for the overpayment error. Selena Horner, PT ton, MI > > > > > Personally I would have a difficult time trying to respond to this letter with any words that are larger than four letters. > > Of course sometimes when I am in a better mood, my thought process is on the high road and I write a response along the lines of: > > " we have a company policy that states all overpayment requests must be made by certified mail, written in swahili and must be received within 90 days of your original payment. " Unfortunately, your request exceeded our policy and therefore, you have exceeded the statute of limitations for requesting a refund. If you believe our policy is unfair, you can make an appeal to the Reimbursement Chair of the Clinic, and they will review your request within 180 days and get back to you. Should you decide that you want to explore this avenue, you will need to submit a page for each CPT code that you feel you paid inappropriately, clearly indicating the patient's name, our account number, the amount we charged, what you actually paid us and how much you feel you overpaid along with a written description from your Medical Director on the validity of the medical necessity of the overpayment refund request. Blah, blah, blah and so forth. Also, make sure your envelope is hermetically sealed..., as failure to do so could make you forfeit your right to this refund. > > Oh..., and good luck, we will be in touch. > > Sorry, sometimes I just write these things for my own amusement, but I hope you find a policy worth implementing somewhere in this email! > > Jim <///>< > > > > > > > UHC overpayment > > > > > Group. > > We are an out of network provider for United Health Care. > > Patients were seen over 12 months ago. UHC is now requesting partial reimbursement for services rendered and paid for at this clinic. Hard to believe, reason stated, they overpaid for services. > > Have any of you had similar requests? > > Did you respond? > > Is there a statute of limitations on such requests? > > Roll > PT Center of Ocean Springs > Ocean Springs, MS > www.ptcos.com > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 8, 2011 Report Share Posted June 8, 2011 Becky Selena's response was obviously a good one and much more serious than mine. In terms of a payer coming back 18 months later and getting their money with the law supporting them, there is not much you can do about that. However, in terms of another payer stating you have exceeded timely filing limits because the first payer took money back after the timely filing statute, you do have recourse. Obviously, this will take administrative time and energy and a willingness on your part to work the system. First, you will need to send the claim in and receive the rejection with the timely filing on it. Then, you will need to submit an appeal with a copy of the request for refund along with a copy of your refund check stating that you billed within one year of receiving the " new " information. Sometimes that will work. Most of the time, insurers will reject your appeal because they want you to go away and not pay. However, you should be able to submit a copy of your appeal to your state senators and legislators (not your US Senators and Congressmen). Enlist their assistance in getting paid. Laws are created to put fairness into play when individuals cannot " play nice " . In this case a one year statute of limitations is not fair and the law was not put on the books to keep benefits from deserving patients. Your illustration is a valid one and would likely win an appeal through assistance by your state legislators and/or assistance from the insurance commission. One other point-if you didn't win the appeal, your example would be an example for legislators to draft new legislation to protect you and your patient's rights. Your illustration is also why I continue to call for all therapists to come together and fight. We have 50+ sets of rules and regulations governing our healthcare. This is absolutely ludicrous. One set of rules for the entire insurance industry to compete on would make a lot more sense (even regional laws would make more sense). But until healthcare providers stand up and fight together, nothing will change. Jim <///>< UHC overpayment > > > > > Group. > > We are an out of network provider for United Health Care. > > Patients were seen over 12 months ago. UHC is now requesting partial reimbursement for services rendered and paid for at this clinic. Hard to believe, reason stated, they overpaid for services. > > Have any of you had similar requests? > > Did you respond? > > Is there a statute of limitations on such requests? > > Roll > PT Center of Ocean Springs > Ocean Springs, MS > www.ptcos.com > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 8, 2011 Report Share Posted June 8, 2011 Jim, As always your advice is extremely helpful. I am going to forward your suggestion to my pediatric providers and encourage them to make this their policy. Thanks so much! Becky A. Sewell, MRC, CRC Rehab Net of AR/ArPTA P.O. Box 202 Conway, AR 72033 ph/fax _____ From: PTManager [mailto:PTManager ] On Behalf Of JHall49629@... Sent: Wednesday, June 08, 2011 8:24 AM To: PTManager Subject: Re: Re: UHC overpayment Becky Selena's response was obviously a good one and much more serious than mine. In terms of a payer coming back 18 months later and getting their money with the law supporting them, there is not much you can do about that. However, in terms of another payer stating you have exceeded timely filing limits because the first payer took money back after the timely filing statute, you do have recourse. Obviously, this will take administrative time and energy and a willingness on your part to work the system. First, you will need to send the claim in and receive the rejection with the timely filing on it. Then, you will need to submit an appeal with a copy of the request for refund along with a copy of your refund check stating that you billed within one year of receiving the " new " information. Sometimes that will work. Most of the time, insurers will reject your appeal because they want you to go away and not pay. However, you should be able to submit a copy of your a ppeal to your state senators and legislators (not your US Senators and Congressmen). Enlist their assistance in getting paid. Laws are created to put fairness into play when individuals cannot " play nice " . In this case a one year statute of limitations is not fair and the law was not put on the books to keep benefits from deserving patients. Your illustration is a valid one and would likely win an appeal through assistance by your state legislators and/or assistance from the insurance commission. One other point-if you didn't win the appeal, your example would be an example for legislators to draft new legislation to protect you and your patient's rights. Your illustration is also why I continue to call for all therapists to come together and fight. We have 50+ sets of rules and regulations governing our healthcare. This is absolutely ludicrous. One set of rules for the entire insurance industry to compete on would make a lot more sense (even regional laws would make more sense). But until healthcare providers stand up and fight together, nothing will change. Jim <///>< UHC overpayment > > > > > Group. > > We are an out of network provider for United Health Care. > > Patients were seen over 12 months ago. UHC is now requesting partial reimbursement for services rendered and paid for at this clinic. Hard to believe, reason stated, they overpaid for services. > > Have any of you had similar requests? > > Did you respond? > > Is there a statute of limitations on such requests? > > Roll > PT Center of Ocean Springs > Ocean Springs, MS > www.ptcos.com > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 8, 2011 Report Share Posted June 8, 2011 Jim, As always your advice is extremely helpful. I am going to forward your suggestion to my pediatric providers and encourage them to make this their policy. Thanks so much! Becky A. Sewell, MRC, CRC Rehab Net of AR/ArPTA P.O. Box 202 Conway, AR 72033 ph/fax _____ From: PTManager [mailto:PTManager ] On Behalf Of JHall49629@... Sent: Wednesday, June 08, 2011 8:24 AM To: PTManager Subject: Re: Re: UHC overpayment Becky Selena's response was obviously a good one and much more serious than mine. In terms of a payer coming back 18 months later and getting their money with the law supporting them, there is not much you can do about that. However, in terms of another payer stating you have exceeded timely filing limits because the first payer took money back after the timely filing statute, you do have recourse. Obviously, this will take administrative time and energy and a willingness on your part to work the system. First, you will need to send the claim in and receive the rejection with the timely filing on it. Then, you will need to submit an appeal with a copy of the request for refund along with a copy of your refund check stating that you billed within one year of receiving the " new " information. Sometimes that will work. Most of the time, insurers will reject your appeal because they want you to go away and not pay. However, you should be able to submit a copy of your a ppeal to your state senators and legislators (not your US Senators and Congressmen). Enlist their assistance in getting paid. Laws are created to put fairness into play when individuals cannot " play nice " . In this case a one year statute of limitations is not fair and the law was not put on the books to keep benefits from deserving patients. Your illustration is a valid one and would likely win an appeal through assistance by your state legislators and/or assistance from the insurance commission. One other point-if you didn't win the appeal, your example would be an example for legislators to draft new legislation to protect you and your patient's rights. Your illustration is also why I continue to call for all therapists to come together and fight. We have 50+ sets of rules and regulations governing our healthcare. This is absolutely ludicrous. One set of rules for the entire insurance industry to compete on would make a lot more sense (even regional laws would make more sense). But until healthcare providers stand up and fight together, nothing will change. Jim <///>< UHC overpayment > > > > > Group. > > We are an out of network provider for United Health Care. > > Patients were seen over 12 months ago. UHC is now requesting partial reimbursement for services rendered and paid for at this clinic. Hard to believe, reason stated, they overpaid for services. > > Have any of you had similar requests? > > Did you respond? > > Is there a statute of limitations on such requests? > > Roll > PT Center of Ocean Springs > Ocean Springs, MS > www.ptcos.com > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 8, 2011 Report Share Posted June 8, 2011 Doug - I agree with Selena.Did UHC pay you more than what you billed? If not, I would assume you billed UHC at your practice fee schedule and it would seem to me that since you are an out-of-network provider you would not be under any obligation contractually to return payments to UHC. I would also respond to UHC like Selena recommended. Good Luck, - Baur, PT Baltimore, MD UHC overpayment > > > > > Group. > > We are an out of network provider for United Health Care. > > Patients were seen over 12 months ago. UHC is now requesting partial reimbursement for services rendered and paid for at this clinic. Hard to believe, reason stated, they overpaid for services. > > Have any of you had similar requests? > > Did you respond? > > Is there a statute of limitations on such requests? > > Roll > PT Center of Ocean Springs > Ocean Springs, MS > www.ptcos.com > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 8, 2011 Report Share Posted June 8, 2011 Doug - I agree with Selena.Did UHC pay you more than what you billed? If not, I would assume you billed UHC at your practice fee schedule and it would seem to me that since you are an out-of-network provider you would not be under any obligation contractually to return payments to UHC. I would also respond to UHC like Selena recommended. Good Luck, - Baur, PT Baltimore, MD UHC overpayment > > > > > Group. > > We are an out of network provider for United Health Care. > > Patients were seen over 12 months ago. UHC is now requesting partial reimbursement for services rendered and paid for at this clinic. Hard to believe, reason stated, they overpaid for services. > > Have any of you had similar requests? > > Did you respond? > > Is there a statute of limitations on such requests? > > Roll > PT Center of Ocean Springs > Ocean Springs, MS > www.ptcos.com > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 8, 2011 Report Share Posted June 8, 2011 I truly love this string! Good 'ol United Healthcare! We've gone " out of network " with several insurers because of the dismal fee schedule. Even though we're out of network, when our bills are submitted another network takes over. In this case, perhaps the insurance had a " back up " network that you were a provider for, but the charges were not processed under that " back up " network, thus causing UHC to ask for a refund. But, I do like the idea of challenging them with a return letter, giving your refund request requirements.. I always think it's odd that we have to file in a timely manner, but they can " file " any time they want to. Viel, Office Manager Mt. Eden Physical Therapy Center 19845 Lake Chabot Road, Suite 205 Castro Valley, CA 94546 FAX www.mtedenpt.com PLEASE NOTE: The materials in this email are CONFIDENTIAL AND PRIVATE, and may contain protected healthcare information. If you are not the intended recipient, be advised that any unauthorized use, disclosure, copying, distribution, or the taking of any action in reliance on the contents of this information is strictly prohibited. If you have received this email in error, please immediately notify the sender via telephone or return mail. From: PTManager [mailto:PTManager ] On Behalf Of baur@... Sent: Wednesday, June 08, 2011 8:12 AM To: PTManager Subject: Re: Re: UHC overpayment Doug - I agree with Selena.Did UHC pay you more than what you billed? If not, I would assume you billed UHC at your practice fee schedule and it would seem to me that since you are an out-of-network provider you would not be under any obligation contractually to return payments to UHC. I would also respond to UHC like Selena recommended. Good Luck, - Baur, PT Baltimore, MD UHC overpayment > > > > > Group. > > We are an out of network provider for United Health Care. > > Patients were seen over 12 months ago. UHC is now requesting partial reimbursement for services rendered and paid for at this clinic. Hard to believe, reason stated, they overpaid for services. > > Have any of you had similar requests? > > Did you respond? > > Is there a statute of limitations on such requests? > > Roll > PT Center of Ocean Springs > Ocean Springs, MS > www.ptcos.com > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 8, 2011 Report Share Posted June 8, 2011 As long as we are on the subject of United Healthcare, I want to continue to point out that when you negotiate a " network " contract with them, their terms (from what I am told-since I do not negotiate contracts on behalf of my clients) are non negotiable. While I am not a legal mind, I believe this is considered a Unilateral contract. If challenged, I believe Unilateral contracts are not enforceable, since one side has undue influence in advancing the terms of the agreement. That said, DO NOT rely on my word, seek legal counsel on the matter if you are not happy. On another note, I have noticed that United Healthcare is very slow to respond directly to Provider complaints. In our company, my staff works over the phone on verbal and written appeals. If those appeals are not responded to within a reasonable period (I would suggest 30 days, since some UHC networks have a 90 day statute of limitations), I have these escalated up to my attention and immediately write complaint letters to the state insurance commission of the provider involved. You can certainly go back to the source of the original department that you complained to, but my experience is that this only delays the process further. By complaining to the Insurance Commission, you are FORCING United Healthcare (or any other insurance company) to work on your issue RIGHT NOW! The BS stops and the payment process kicks in again. I have taken this approach because UHC works very slow to resolve issues and doesn't seem to really want to pay. The insurance commission will address your issues AND take an insurer to task. And while I cannot know every state insurance law, I believe that if enough complaints are lodged, an insurer will have undue scrutiny from state auditors and their lives will become a regulatory hell that they put providers through. I am hopeful that since an insurance company will not change their ways, a state regulatory commission might help them reconsider their how they do business. Okay, off my soapbox once more..., I apologize if some of you are getting sick of my 2c! Jim <///>< Rehab Management Services Cedar Rapids, IA Blah, Blah, Blah and so forth 319/892-0142 www.rehabmgmt.com UHC overpayment > > > > > Group. > > We are an out of network provider for United Health Care. > > Patients were seen over 12 months ago. UHC is now requesting partial reimbursement for services rendered and paid for at this clinic. Hard to believe, reason stated, they overpaid for services. > > Have any of you had similar requests? > > Did you respond? > > Is there a statute of limitations on such requests? > > Roll > PT Center of Ocean Springs > Ocean Springs, MS > www.ptcos.com > > > > > > > > Quote Link to comment Share on other sites More sharing options...
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