Ask the Experts: Managing Health Plan Overpayments

I have heard there is a rule that health plans cannot recoup overpayments that are more than one year old. Does that stipulation vary by state, or is that a rule that is negotiable per contract?

Answer 1: The rule varies from state to state. For example, Alabama is 12 months while Arkansas is 18 months, and there is not limit in Alaska.

This question was answered by: David A. Williams, CPA, FHFMA, partner, Horne LLP, and a member of HFMA’s Mississippi Chapter.

Answer 2: This is an issue that you can address in the contract. Not all payers will agree to it, but it is worth a shot. Of course, federal programs can take back payments with no regard to time frames, so there is no negotiating on this point with them.

This question was answered by: Brenda Loper, regional director of access services for four Sentara Healthcare hospitals.

Answer 3: Yes, it varies by state, and yes, you should try and negotiate some limits into your contracts if possible. I would recommend negotiating time limits as well as some parameters regarding the volume of records they can review routinely each year. Health plans sometimes get offers from third-party companies promising to find issues who then come to you asking for large numbers of medical records.

This question was answered by: Ruth Landé, vice president, patient revenues, Memorial Sloan-Kettering Cancer Center, and a member of HFMA’s Metropolitan New York Chapter.

Answer 4: I concur with David’s comments. Yes, it varies by state, but not all states have regulations.

This question was answered by: Michele Marcum, CHFP, senior network manager, Aetna, and a member of HFMA’s Idaho Chapter.

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