The dreaded takeback, clawback or otherwise known as overpayment recovery, is an unwelcomed request to receive from an insurance provider. For a variety of possible reasons, the insurance payor believes that they have overpaid a medical provider for claims submitted, and now the insurance company is requesting a refund.
Physicians and other health professionals may feel that it is easier to simply pay the insurance provider, versus challenging the insurance payor with an appeal. However, successfully appealing takebacks is possible without having to spend an unreasonable amount of work.
At RevUp Billing, we have discovered that the more organized and persistent a medical practice is, the better chance they have of winning their appeal. However, in order to file a successful appeal with the insurance providers, healthcare practices need to follow these three basic steps.
Know the exact appeals process for the insurance company requesting the takeback. In general, it is the same principle, but every insurance provider and medical specialty is slightly different in their policies and regulations.
Healthcare professionals should check the language in their insurance contract. What they believe was negotiated into their contracts, versus what is actually printed is sometimes different. Regardless of the insurance provider and contract language, every appeal request should include the following information:
Every date is different in how they require insurance companies to perform takebacks for overpayment. Most of the time, there is a limited window of time that allows insurance payors to file a takeback request. For example, in Ohio, regulations state that for adjustments (takebacks) to previously paid claims, insurance payors have two years from the date of the payment in question to request a takeback.
Many states have similar insurance laws, however healthcare professionals should know their state's individual statutes that relate to this topic.
A medical practice needs to actively address any alleged overpayments, even though the investigation may take time and resources away from direct patient care. Healthcare providers need to explore whether this is a one-time occurrence, or is there a larger problem.
The AMA (American Medical Association) recommends that all physicians accurately record and track their communications with insurance payors. These records should include names, takeback request information as well as appeal attempts and outcomes. To make this process easier, the AMA has even included “Tools for proper payment & appeals” on their website.
Insurance companies are very large, which means files and requests are sometimes miscommunicated or even lost. If a healthcare provider does not understand or feels that information is missing, they should promptly ask for clarification from the insurance payor. Phone calls and emails are quick and convenient, but something in writing sent via certified letter is the best option. Emails are sometimes not received, but certified mail provides proof of delivery.
Ideally, communication should leave a clear paper trail so both parties have a clear record in writing. In order to minimize confusion, one person should track the appeal throughout the process. Open hostility and poor behavior will not convince an insurance payor to reverse the request for an adjustment of a previously paid claim. A level and rational approach is what will successfully move this process forward. Of course, the best way to win a battle is to not have the battle.
This means that a medical billing department or healthcare revenue cycle management service needs to actively manage all submitted and rendered insurance claims. A good claims management & denial system will greatly reduce (or eliminate) the number of takeback requests.
If you have additional questions about insurance company takebacks, payment adjustments and general strategies that healthcare providers can employ to prevent this occurrence – contact us.
Updated from original article published on November 7, 2017
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