Pulmonology Coding Alert

Question: Two years ago, we saw a patient who came to our office for shortness of breath. Her insurer later wrote to us and said we had to refund an overpayment that the insurer sent us at the time. Our contract with that insurer doesn’t list a statute of limitations, so we don’t believe we have to send it back, but our administrator says we should. Who is right?

Missouri Subscriber

Answer: Typically, the determination of a statute of limitations is made in accordance with state laws, and not by a contract with the payer. According to the Missouri Revised Statutes, which the state published on Aug. 28, 2016, “All health carriers shall … Not request a refund or offset against a claim more than twelve months after a health carrier has paid a claim except in cases of fraud or misrepresentation by the health care provider.”

Therefore, unless a healthcare attorney advises you differently, you should follow the 12-month rule that your state has dictated, which would mean that you may not need to return the overpayment, assuming that you collected the reimbursement more than twelve months ago.