Check the validity of the denial
It's not uncommon for insurance companies to use creative, yet inappro-
priate, tactics to enhance their profit margins. Even though providers
will sometimes dispute or appeal overpayment allegations, payers may
continue to move forward with the process, ignoring their obligations
and offsetting the disputed amount on future claims until the refund is
granted.
To fight back, first evaluate the validity of a benefit denial or refund
demand. If you can show that the insurer made the error that led to
the alleged overpayment or if there was, in fact, no overpayment at all,
you'll have more success during the appeal process. Never just assume
a payer's findings and statements are accurate.
To judge the validity of the denial, start by asking a few questions
about the refund demand and claim in question, including:
• Did the facility initially receive the entire payment for all services
rendered, including for implants, splints and radiology?
• Were there any services or items that were underpaid or unpaid?
• If a service was unpaid due to an error, who made the initial error?
• Are the insurer's billing allegations factual?
• Do you suspect that the payer violated any compliance require-
ments, like appeals or other notification requirements, in issuing the
refund demand or denial?
An invalid request?
If you find yourself suspecting that the refund request isn't valid, it's
time to take action. You're required to refund overpayments only
when there is clear evidence of "unjust enrichment" of the claim or
for services not rendered. Even if you've been overpaid, it's crucial to
determine where the error stemmed from. If the insurer mistakenly
paid the claim, don't take ownership of it. Appeal the refund request
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