Medicare Compliance & Reimbursement

Question: Our doctor performed surgery on a patient 11 months ago. We just learned that the patient had primary and secondary insurance at the time. The payer she said was secondary was really primary. The secondary insurance company paid us as primary, however. Are we obligated to refund the money even though it's been almost a year?

Answer: Since you find out about the error -- for example, if the patient called your office several months later and explained the situation -- you should call the payer and let it know of the error. Then, leave it up to the payer as to how to proceed. The payer may not do anything because so much time has passed, or it may work directly with the patient to solve the problem.

Good news: If a patient makes a mistake and gives the secondary payer as the primary, the insurance company will hopefully catch the error and then pay at the secondary rate. Obviously, in this case, that didn't happen. If the secondary insurance paid the claims as a primary because it was unaware of other insurance and your practice also did not have any knowledge of the primary payer, then your practice should not be held liable.

Bottom line: If a patient presents you with information on what she thinks is her primary insurance, and your practice finds out much later that it was her secondary insurance but you were paid, talk with the payer.