Wiki Overpayment / Refunding questions about fraud

[Katrinahoward76]

I am trying to gather information about some billing processes, namely Medicare. But, private payors are included as well as patients themselves. I am concerned with possible fraud and intent to nip anything in bud.


I am good with general info on reimbursements but I have some specific questions.


1. When Medicare or Medicaid notifies you of an over payment and you tell them to recoup, how long do they have to complete this process? Whose burden does it lie on if they do not recoup after being told to and we know about it? We know we have an over payment. We faxed back to Medicare, the private payor, or medicaid to recoup and they still have not done it. We do not receive any confirmation from Medicare ect.. that they received the response other than a fax confirmation.



2. If there are credit balances due to both patients and insurance companies from a business no longer producing claims should those be refunded directly? We went from an INC to an LLC with a new Tax ID. The INC no longer has any claims going out so there are no EOB's or payments to recoup from. We have refunds and over payments to give back. Wanting to know the proper process for completing this.


3. How do I show that writing off invoices / claims as bed debt when they are not is wrong? I have found where there are cases that rejections did not get worked or a claim never filed and then get wrote off as bad debt to remove them from the AR.


Thanks for your help. Any documentation that I can be directed to would be great. I have read and read, but I can't find anything to directly answer my questions. I want to make sure my organization is doing things correctly.

Kat

 

[Leenahz]

I am trying to gather information about some billing processes, namely Medicare. But, private payors are included as well as patients themselves. I am concerned with possible fraud and intent to nip anything in bud.


I am good with general info on reimbursements but I have some specific questions.


1. When Medicare or Medicaid notifies you of an over payment and you tell them to recoup, how long do they have to complete this process? Whose burden does it lie on if they do not recoup after being told to and we know about it? We know we have an over payment. We faxed back to Medicare, the private payor, or medicaid to recoup and they still have not done it. We do not receive any confirmation from Medicare ect.. that they received the response other than a fax confirmation.



2. If there are credit balances due to both patients and insurance companies from a business no longer producing claims should those be refunded directly? We went from an INC to an LLC with a new Tax ID. The INC no longer has any claims going out so there are no EOB's or payments to recoup from. We have refunds and over payments to give back. Wanting to know the proper process for completing this.


3. How do I show that writing off invoices / claims as bed debt when they are not is wrong? I have found where there are cases that rejections did not get worked or a claim never filed and then get wrote off as bad debt to remove them from the AR.


Thanks for your help. Any documentation that I can be directed to would be great. I have read and read, but I can't find anything to directly answer my questions. I want to make sure my organization is doing things correctly.

Kat

Hi Kat,

As part of the ACA laws, I believe providers have 60 days to refund overpayments to insurance companies upon finding them, regardless if the provider has instructed them to take back their money.

As far as the bad debt situation goes, my definition of a bad debt is a balance I've written off after the patient has been billed X amount of times. Our office would collect then collect the bad debt at the time of their next appointment.

When I would work the A/R and come across old claims that I knew had been filed, but never actually "worked," I would do my best to research the reason for non-payment and adjust accordingly. If it was due to an authorization or a medical record request that wasn't done in a timely manner we would use an adjustment code of "timely filing" or "office write-off" depending on the situation. A bad debt to me is something still owed to the practice, so claim rejections wouldn't necessarily fall under this category, especially if the work wasn't done by the provider's office to get it paid.

I'm sorry I don't actually have any resources I can provide, but this is my experience

Lena