Ask the Experts Answer: Provider Refunds for Insured Patients

Q: Do you know of any policy/legislation or general practices regarding a provider refunding a payer if the patient was authorized but then later found by the payer to be uncovered because they are secondary?

A: Many states have legislative and regulatory requirements regarding provider refunds for insured patients. First, it is advisable to review your state laws, rules, and regulations on this subject matter, as the requirements from state to state may vary considerably. As a general rule, the provider is responsible for refunding a payer’s payment if the patient is later found to be ineligible for coverage. However, the length of time the payer has to request a refund from the provider once payment has been made may vary by state. We have seen the time period a payer has to request a refund range from as few as 180 days to 36 months. Most state legislative and regulatory requirements require the payer to submit refund requests in writing, allowing the provider to refund the overpayment within a specified time period or the opportunity to initiate the appeal/reconsideration process. It is advisable to negotiate a retro-eligibility limit within your payer contracts along with limits on automatic recoups and non-related account offsets.

Dawn Boyd answered this question