Wiki Retraction of payment from 2011

[kaylawardle]

Hello!
I was hoping to get some help with a claim.. I am getting very frustrated and I don't know how to handle this.

We saw a patient on 04/29/2011 and billed Care Improvement Plus for insurance payment. In July 2011, we received the payment.

Three years later, in July 2014, we received a payment retraction. This stated that the insured had another primary insurance (UHC) and that they weren't responsible for payment.

At this time, nothing was done. Then, 6 months later in January 2015, I found out about this and decided to make an appeal, as this seemed erroneous to me.

I received the appeal review today, and they stated

"Based on our review of the information provided, Care Improvement Plus has upheld the original decision. This claim reconsideration has been processed in accordance with the applicable rules under the CMS Medicare Managed Care regulations and guidelines and Medicare's billing guidelines. After careful consideration of the available information the following determination has been made:
"Claim cannot be reconsidered as primary carrier EOB is missing, CIP cannot pay the claim as primary as other carrier is already there for DOS."​

At the time of service, no other insurance was provided to us by the patient. In addition to this, CIP paid for the claim, giving us no reason to suspect otherwise. Now, over three years after the initial appointment, they are trying to retract payment. This means I am past time for filing with UHC so we are just out the money for this claim?

What should I do? I feel like CIP is wrong.

 

[mitchellde]

You should inquiry with the patient as to whether they indeed had UHC coverage at that time.. If they did and withheld the information, then you can bill the patient. If they were not and show proof of discontinuation of coverage, or that they were never covered by UHC then the patient will need to contact CIP and find out what subscriber info was used to check them UHC in the first place. This is bigger than something you by yourself can manage, you need the patient input.

 

[suemt]

The biggest problem here is waiting so long to respond. All practices should have a process in place to triage all the different kinds of mail that comes into the practice so these types of letters can be handled timely.

Querying the patient can be helpful, but I suggest requesting complete OHI (other health insurance) information from the original payor. They cannot recoup the payment because there MIGHT have been other insurance, they have to provide details (because otherwise how do they know that the Met Life insurance isn't dental or homeowners instead of medical?) you should be able to query the other insurance company to confirm or deny coverage. Since this is a Medicare patient, the CWF will contain details of any OHI including plan and policy number.

Also, many patients are truly confused about their insurance and don't always understand the nuances of changing plans, different insurance company names, etc. It isn't always easy or possible to go after them.

Often these attempts at recoupment are processed by contingent fee contractors (aka bounty hunters). They make a ton of money by either hoping practices will ignore these requests, or they make it extremely hard to communicate with them about it.

 

[TangieWilliams]

If you receive a retractions form an insurance carrier years after the DOS. You can bill the other payer and be paid past timely. You just need to send proof of the retraction and it starts your time line again. However if you waited 6 months to work the account and that is past your timely you would not get paid and would bill patient. As long as you didn't bill and get a timely denial. If you appealed the date of the answer on your appeal would be when your clock starts again also. I relies this is a very old question but i thought someone might still need this information. Thank you.