Wiki Recoupment questions

[corinecorral@yahoo.com]

Good evening everyone,

I live in California and work as a Claims Analyst. I have been disputing an invalid recoupment for one patient and was completely shocked to find that they took the money from a different patient's claim payment. My co worker emailed me the EOB showing what happened and was asked to write an appeal. I am told that this is not legal, but would like to verify this before I respond. I have found information showing that they can take from future reimbursement of the same patient but, not nothing showing that they can take from reimbursements of a completely different patient. I have not written a letter like this before and need assistance on finding California Statutes that can be used for this situation and others. Any assistance would greatly be appreciated.

Thank you,

Corine

 

[thomas7331]

There was a recent lawsuit involving United Healthcare on this question about 1-2 years ago that was in the news that you may be able to locate for some additional information. As I understood the case, it was only illegal to recover money against payments that were made from a different source account. So, for example, if one patient was covered by a certain plan, any offsets had to be made against other payments from that same plan's account. As I remember, United was penalized because they were offsetting across different plans which was considered an unaccepted accounting practice.

So I believe that if both patients are covered by the same policy, such as two Medicare Advantage patients, or two patients who are both covered under the same employer's plan, it is legal to do this since those funds are all from the same source. Hope this helps some.

 

[CodingKing]

Plan I worked for never crossed over from "checkbooks"

ASO from ASO
Fully Insured from Fully Insured
Medicare Advantage from Medicare Advantage
Medicaid from Medicaid