By Martine G. Brousse (not AI!)
"The Medical Bill Whisperer"
Patient Advocate, Certified Mediator
AdvimedPro
March 4, 2024
Do you know the status of every account you have with every medical provider and facility that you consulted or that treated you? Are you sure they can be trusted to refund you what you might have overpaid?
As a previous billing manager, I can attest to an ugly but all too common practice (not mine though!) : credits owed to patients are not always issued. Sometimes, they are not even identified unless you ask.
A refund is owed to you if:
· You paid something to a medical provider AND
· Your insurance payment and/or adjustment calculated your final liability to be lower than that payment
But is time to come clean with patients who are, after all, customers. Doesn't your credit card company statement show refunds and credit balances? Doesn’t the supermarket clerk give you change when you handed over too much to cover the receipt?
Medical providers are subject to the same rules of commerce. If you paid more than you truly and legally owed, then a refund is due.
A. From the medical provider's POV:
Overpayments that remain in a practice’s or hospital’s books improve the accounting (showing more income and increasing the credit rating), and provide additional general funds. Payment processing errors – such as “forgetting” to apply a contractual adjustment – also disguise potential refunds as “account paid in full”.
Insurance reimbursements take a couple of weeks at best, months at worst. Charges may be denied then appealed for months. Few providers can afford delays before they are paid properly. Patients are billed soon, if not immediately, even if their final liability has not yet been confirmed.
At the beginning of the year, patients are routinely asked for payment of unmet “share of cost”: deductible, and co-insurance. While an office or ER co-pay can be asked for in advance, your final liability may be lower once these charges have been processed.
The other side to this sad story is "office policy". Don't ask? Don't get!
B. Common reasons for credit balances:
· Pre-paid Share of Cost: At the beginning of the year, patients are routinely asked for payment of unmet “share of cost”: deductible, and co-insurance. While an office or ER co-pay can be asked for in advance, other claims in process - from other providers - would lower if not cover your SOC by the time this specific claim went through the insurance system. You would have paid one provider for something owed to another.
· Hasty Billing: Any “estimate” or “pre-pay” statement remains subject to final insurance determination. Your final liability is only established once an EOB has been issued, or an appeal decision finalized.
. Hasty Payment: your claim had not been processed before you pay the first bill, and the EOB will show a lower final liability to you. Or this is a case of “no pay, no service”, too common with out of network providers. However, those charges should still be submitted to the insurance, as a payment might be due by your insurance.
· Double coverage: you pay before the secondary carrier has processed the claim, or has even been billed. Or both policies pay, the combined total exceeding the amount billed by or owed to the provider. Or a contractual adjustment was not properly applied, burdening you for an amount which the provider should have written off.
· “Don’t ask, don’t get”: Whether by written agreement or “office policy”, some providers may not refund you when an overpayment is identified (if at all!). These may or may not be entirely kosher, as some State and Federal mandates force refunds to be made within a limited amount of time.
· Fear/Risk of insurance recoupment: A recoupment is the way an insurance demands a payment back from a provider, due to a processing error, overpayment, or payment made in error (no eligibility for example). This is a reason routinely used by billing managers to refuse an outright refund to you. However, the risk of something being recouped is extremely low, and usually can be spotted ahead of time for a specific reason (double payment, paid to the wrong provider, denied charge being paid, non-covered service being paid etc)
C. What can/should you do?
· Due Diligence: Keeping track of your bills, insurance explanations of benefits ("EOB") and payments is crucial. Any liability listed on an EOB that does not match that listed on a provider statement is a red flag.
· Account maintenance: Request a copy of your ledger, or itemized bill, at the end of each year, or after a visit to a medical facility. Useful for tax purposes, it will allow you to scan for errors and confirm balances.
· Demand clarity: Get receipts for any payments, especially if paying cash. Indicate whether this is an advance on a yet-to-be-determined liability, pre-payment of your unmet share of cost, payment for a service deemed not-covered by your insurance, a monthly payment or payment in full. Conditions and time frame of a potential refund should also be specified.
· Avoid paying in advance, except for co-pays as those are due at every visit. Anything else should wait for confirmation on an insurance Explanation Of Benefit (“EOB”), especially if the provider is In Network.
· Consult legal mandates
Some States have laws in the books limiting such recoupments (365 days in CA for example).
Obamacare (the “ACA”) mandates refunds be identified and made within 180 days. Check with your State’s authorities for its specific guidelines.
If the office “policy” allows for more than your State’s mandates or the ACA, make sure to get a good explanation in writing (i.e. service authorization was denied, service excluded from policy etc). The Terms of your Policy should also indicate how long an insurance has to legally recoupment a payment and under what conditions/reasons.
· At any suspicion or proof of overpayment, ask for a refund in writing. Add any evidence such as an EOB or legal mandate. Do set the appropriate (legal) deadline for the refund to be issued by indicate the specific date it is due. If your request is denied because of “office policy” and there is no State law on your side, Federal law may still apply.
D. If a refund demand is refused or ignored:
· An In Network provider (one contracted with your insurance) is obligated by contract to refund you if you overpaid. Contacting your insurance for help usually yields immediate results. In my experience, refunds are issued quickly after a conference call with the insurance’s representative or if they issue the provider a “Cease and Desist" letter demanding an immediate refund.
· Escalate the case with filing a complaint with your insurance against this provider for "improper financial practice". The insurance has the option to cancel their contract as a way to entice proper financial behavior.
· I have successfully brought a few such cases to the State’s Attorney General’s office…and won! This might be a better option for Out of Network providers, over whom your insurance has no legal oversight. An order to pay coming from the AG usually receives prompt attention.
· Filing a claim in Small Claims Court is also an option, as is consulting with an attorney in cases where a larger refund is due. Hopefully, such issues can be settled before this step is undertaken.
In conclusion:
“Good accounting makes for the best of friends” would repeat my mother. This goes for your medical practice or hospital. You should be able to trust the billing dept as much as you trust the medical staff. Care is not only clinical, but financial as well. After all, would you refer anyone to a practice or hospital where you have felt (or been) taken advantage of or even ripped off? Trust is built on cooperation, communication and transparency. From front AND back office.
Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.
(424) 999 4705 - F (424) 226 1330
@martine brousse 2024 @ the medical bill whisperer 2024