APMA News - July/August 2017 - 32

Reimbursement

Recoupment-How Podiatrists Can Protect Themselves
There are a variety of reasons why private insurance companies might try to seek repayment of previously paid claims:
Overpayments for a covered service where
there is agreement the service provided
was covered, but the insurer claims it either paid the podiatrist too much or that
duplicate payments were made
Retroactive denials where the service was furnished and paid for, but the insurer subsequently
claims it should have been denied initially
Miscoordination of benefits and payments

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Be aware of the factors governing these recoupment requests when they occur, as the reason for the request determines your response options. The first place to check when you
receive a recoupment request is your contract with the insurer.
There will usually be contractual provisions that allow for retroactive payment adjustments and address patients' benefit ineligibility, methods for adjusting or recouping payments, and prior authorizations. Podiatrists should be proactive in seeking to

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32 APMA News July/August 2017

Contact the APMA Health Policy and Practice
Committee at healthpolicy.hpp@apma.org.

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change or delete problematic provisions. Be alert for
these provisions when signing new contracts.
The second reference for recoupments should
be state laws and regulations. Check to see if
your state addresses recoupments, either via
prompt payment rules, limits on look-back periods, procedures an insurer must follow when
requesting a recoupment, or circumstances under
which recoupment is prohibited. This information appears in your state prompt payment statute or sometimes in
the laws governing unfair or fair insurance practices or claims
settlement rules. There might be rules regulating specific
types of insurers (e.g., managed care plans, indemnity insurers,
HMOs). Also, some laws address only recoupments due to
"retroactive denials," while others address recoupments due
to overpayments.
A third factor that has an impact on recoupments is the
Employee Retirement Income Security Act of 1974 (ERISA).
State insurance statutes and regulations concerning recoupments or prompt payments are preempted by ERISA where
the plan in concern is a self-insured employer plan. Please
further note there can be significant differences among courts
on ERISA issues.
Finally, common law is another tool you may be able to
use in fighting an insurer recoupment. The degree of support
common law provides a podiatrist objecting to a recoupment
depends largely on the specific facts of the recoupment. For
example, common law may generally support a podiatrist
who objects to a retroactive denial by citing member ineligibility, but it is less likely to support a podiatrist who objects
to a recoupment that is based on duplicate payments to the
podiatrist for the same service. Indeed, at least one exception
has been used in favor of health-care providers in cases where
insurers have mistakenly paid them for services that were not
covered or that were covered at a lower rate than the rate paid.
In several cases where the overpayment to the provider was
favorably upheld, a common theme is that the insurer was in
a better position to know whether the services were covered
and the health-care provider was not unjustly enriched by
the payments.
To read more about recoupments and private insurance topics, review APMA's Private Insurance Resource Guide at www.
apma.org/PIRG. Learn more at APMA's "Recoupment Law and
Resources" page, at www.apma.org/statereferencemanual. n

http://www.apma.org/PIRG http://www.apma.org/PIRG http://www.apma.org/statereferencemanual http://www.totalvein.com

Table of Contents for the Digital Edition of APMA News - July/August 2017