Friday, 3 October 2014

UHC overpayment - How to resolve?


If you identify a claim for which you were overpaid by us, or if we inform you in writing or electronically of an overpaid claim that you do not dispute, you must send us the overpayment within thirty (30) calendar days (or as required by law), from the date of your identification of the overpayment or our request. We may also apply the overpayment against future claim payments to the extent permitted by your agreement with us and applicable law.

All refunds of overpayments in response to overpayment refund requests received from United Healthcare, or one of our contracted recovery vendors, should be sent to the name and address of the entity outlined on the refund request letter. Refunds of any credit balances existing on your records should be sent to:

UnitedHealth Group Recovery Services
P.O. Box 740804
Atlanta, GA 30374-0804

Please include appropriate documentation that outlines the overpayment, including member’s name, health care ID number, date of service and amount paid. If possible, please also include a copy of the remittance advice that corresponds with the payment from UnitedHealthcare. If the refund is due as a result of coordination of benefits with another carrier, please provide a copy of the other carrier’s EOB with the refund.

When we determine that a claim was paid incorrectly, we may make claim reconsiderations without requesting additional information from the network physician, health care professional, facility or ancillary provider. In the case of an overpayment, we will request a refund at least thirty (30) days prior to implementing a claim adjustment, or as provided by applicable law or contractual agreement. You will see the adjustment on the EOB or Provider Remittance

Advice (PRA). When additional or correct information is needed, we will ask you to provide it. If you disagree with a claim reconsideration, our request for an overpayment refund or a recovery made to recoup the overpayment, you can appeal the determination (see Claim Appeals section of this Guide).

Overpayment Recovery Program - BCBS FLORDIA update

Effective February 27, 2012, Blue Cross and Blue Shield of Florida, Inc. (BCBSF) will implement additional changes to our Overpayment Recovery Program. These changes relax certain netting rules so our claims system can net (offset) overpaid funds quicker and more efficiently. Our new netting rules should make it easier for providers to reconcile accounts when it is necessary for BCBSF to recoup overpaid amounts.

Netting Across Lines of Business

• BCBSF will now offset overpaid amounts across different lines of business. In the past, because of  system limitations, BCBSF was limited to offsetting against the same type of claims only (e.g., State Group, Federal Employee Program (FEP), etc.) However, our claims system will always attempt to  recover overpaid funds from claim payments for the same line of business first before netting from a different line of business.

• There is no change to remittance advice data. You will see the same claims data that you see today.

Netting Across Different Addresses

• BCBSF will now offset overpaid amounts across different addresses (provider locations.) In the past,    we did not offset against different locations (addresses) operated by the same provider or physician   group. However, effective February 27, 2012, we will offset against another address if funds are not  available from the provider address (location) that was overpaid.

• The remittance advice will show details including the impacted provider name, provider number and claim(s) information to assist in reconciling accounts.

 Overpayment Disputes

• BCBSF may offset the portion of an overpayment that is not in dispute.

Example: BCBSF overpaid Dr. Jones $500. However, Dr. Jones disputes $300 of the overpayment. BCBSF may net (offset) the $200 amount not in dispute to go toward the overpaid amount, even if the dispute is not resolved.

Additional Information

• Providers may experience netting more frequently, because our processes expedite recovery of overpaid funds.

• To avoid netting, you must submit a payment to BCBSF within 40 days from the original request   refund (invoice) letter date, along with a copy of BCBSF’s request refund letter.

• If you do not submit the overpaid amount to BCBSF within 40 days, BCBSF will begin the netting    process.

• For general information about BCBSF’s Overpayment Recovery Program, providers may refer to the online Manual for Physicians and Providers at; select the Providers tab, Provider Manual and refer to the Overpayment Recovery Program section.

BCBSF will continue to enhance its Overpayment Recovery Program to increase efficiency and streamline processes. We will keep you informed as other changes are implemented. If you have additional questions, call the provider Contact Center at (800) 727-2227.

Overpayments - physician resoponsibility and disagreement


An overpayment occurs when Medicare pays more than the correct amount, often due to the following: Duplicate submission of the same service Payment to the incorrect payee Payment for excluded or medically unnecessary services Payment made as primary insurer when Medicare should have paid as secondary insurer All Medicare payments, correct and incorrect, are transmitted to the Internal Revenue Service (IRS). 

If the payee is incorrect, Medicare must request return of the monies and reprocess the services correctly. Physicians must also take specific steps when overpaid by Medicare.

Physician Responsibilities in an Overpayment Situation 

If Medicare pays more than the correct amount in error, the overpayment should be refunded as soon as possible, without waiting for notification. The local carrier can provide information regarding where to mail the refund. The following must be included with the refund: 

* The provider number (and that of the provider who should be paid, if applicable) 

* The Medicare number of the patient(s) in question, date of service, and amount overpaid 

* A brief description of the reason for the refund 

* A copy of the remittance notice, highlighting the claim(s) at issue 

* A check for the overpaid amount

If Medicare Discovers an Overpayment Before Refund is Made 

Medicare will send a letter listing the service(s) at issue, why the overpayment occurred, and the amount being requested. The physician will have 30 days from the date of the letter to mail a refund to the address in the letter. 

If the refund is not received within 30 days from the date of the first letter, a second letter will be sent and the balance due will be satisfied by withholding future claim payments until the overpayment is paid in full (otherwise known as “ offset ” ). When Medicare notifies the physician of an overpayment, and multiple claims are involved, the letter will describe all over- paid claims.

Physician Disagreement with the Overpayment  

The physician has the right to appeal the decision if he or she disagrees with the overpayment. How- ever, submitting an appeal does not prevent an offset. An explanation of why he or she believes the overpayment to be incorrect should be included with the appeal.

Medicare Collects Interest on Unpaid Overpayments  

Medicare is required to collect interest on overpayments not satisfied within 30 days from the date of the initial refund request letter.

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