health insureance.. they paid now they want it back

[Subandera]

What is the name of your state? Florida

I had surgery in Jan 2005. I have a supplement in addition to my primary insurance. The supplement required that I submit an itemized bill which I did. Their payment was a little over $2000 which is about what I expected. I received the check 3 weeks ago, cashed it and paid outstanding medical bills with the proceeds. Today I get a letter in the mail saying they received statement from the surgery center that some of the bill was for "professional services" which they do not pay for and they want about 3/4 of thier money back. My questions: #1 I submitted the documentation they required and they paid, so I have to pay it back? It wasn't a mathematical error! #2 Since I have spent the proceeds on medical bills, I don't have the funds to pay it back so what are my options if i am legally required to pay back? I was under assumption that expt for fruad or mathematical errors, that when you got the check the money was yours! Please if anyone knows state law, national law or case law, please help!

 

[Subandera]

thought sure someone would have been in same situation as I, btu I guess they haven't.

 

[cbg]

Sorry, but you asked for national, state or case law on the subject and I don't have any for you.

The only suggestion I can offer is that you talk to your state insurance commission's office. They should be able to tell you if the practice is permitted under the circumstances you describe and in your state.

 

[ablessin]

ok - for starters- it's not YOUR money - your insurance gave you a check - your forwarded ALL of it on - GOOD for you - I can't tell you how many patients DONT do that.
YES - the insurance carriers do what is called a "post payment review".

Following the review, they CAN and DO take money back because they have paid in error.

Normally- the insurer would collect the inappropriate payment from the facility/physician.

Call your insurance carrier and ask them to deal with the doctor's office to recoup their money. Tell them that you forwarded the payment on - you should not be required to re-imburse them out of your pocket.

However - IF professional expenses are not a covered benefit- the physican can bill you for unpaid balances after insurance "payments" are finalized.

Hope that helps

 

[somarco]

I suggest you review the terms of your policy, perhaps with the assistance of the agent who sold you the plan. Compare benefits and exclusions in the policy with the submitted claim and the EOB from the carrier.

It may be that the claim was indeed paid in error . . . or that the claim was miscoded by the provider.

Certainly worth checking out.

 

[somarco]

Normally- the insurer would collect the inappropriate payment from the facility/physician.

Call your insurance carrier and ask them to deal with the doctor's office to recoup their money. Tell them that you forwarded the payment on - you should not be required to re-imburse them out of your pocket.

In this case the payee was the insured, not the provider.

The money was paid to the insured, and that is who the carrier would pursue for reimbursement. The carrier has no direct knowledge how the funds were used. Absent a formal assignment of benefits, the carrier has no financial tie to the provider(s).

Even IF the carrier pursues reimbursement from the provider, and is successful, the patient is still responsible for the bill. If the carrier obtains a refund from the provider, that provider will then go back to the patient for payment.

 

[Subandera]

I think possibly I rambled and left out soem important facts here. The insurance company did send me the check. This was not my primary insurance. Its one of those thats pays "x percent" directly to the person with the insurance. I deposited the check then used the funds to pay physicains, radiology, lab etc that was a part of the procedure but not a part of the claim per se. The polcy pays on insititutional bills (hospital, surgery center etc) so I used the funds to pay towards other related expenses. So now they want the $ back and I do not have it....

 

[somarco]

You have a right to dispute their "new" interpretation of the claim. But if they did indeed overpay the claim, you owe them the money.