What happens if an insurance company overpays you?

If the payer confirms that they made an overpayment, they must reprocess the claim to prove that the payment is correct and submit a request to the supplier to return the overpayment. Sometimes, the payer will simply ask the provider over the phone to return the overpayment. If the insurance company overpays for a claim, the provider's representative must re-investigate to ensure that the credit is correct. If so, contact the insurance company and ask them to explain how they handled the claim that resulted in an overpayment.

If the credit is valid, ask the insurance company if they have a process to recover the overpayment. If the insurance company can't or doesn't want to recover the money, ask it to reprocess the claim and submit a formal request for reimbursement. If the provider receives a request for reimbursement that, after speaking with the insurance company, determines is not valid, the provider's representative can file an appeal for the insurance company to review the claim for processing errors. It's important to address this issue as soon as possible, as the contract with the insurance company may have definite deadlines for appeal.

The insurer filed a lawsuit against the defendant to recover the erroneous payment, claiming that his mistake was excusable. Under the general conditions of the policy, the insurer was obliged to pay the transferee. Such an agreement is not unusual in cases where out-of-network providers are involved, says Susan Pisano, a spokeswoman for America's Health Insurance Plans, a trade group. Insurance policies often contain text stating that if the insurer overpays, the insured person has an obligation to help recover the money, perhaps by providing information to the insurer or even testifying in court, Barlow says.

Among the many questions that have yet to be answered, she's not sure why the insurer is turning to her and not to the provider. The Court of Appeal accepted the insurance company's appeal and issued a summary judgment order against the insured. Sometimes, patients can be involved even if the insurance company doesn't seek them out to recover an overpayment, experts say. After the death of the defendant's mother, the defendant claimed the full benefit provided for in the policy, which he asked the insurance company to deposit directly into his account, and the insurance company did so.

CareFirst BlueCross BlueShield, which insures Dowden and her husband through a plan for federal government employees, said in a statement that, under its contract with the Federal Office of Personnel Management, it is required to try to recover any overpayment it identifies. The insurance company then realized that it had mistakenly paid the defendant the full benefit provided for in the policy and, subsequently, paid the share due to the defendant's brother. Whenever an overpayment is discovered, providers must document all phone calls, correspondence, and checks, both with the patient and with the insurance company. For example, an insurer may simply make a mistake and pay a provider more than the amount contracted for a service.

Gertraude Jackel
Gertraude Jackel

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