Sometimes an office is reimbursed too much money for services provided, which results in an overpayment. The insurance carrier usually makes the overpayment, but sometimes the patient makes it. In either case, it is important that the overpayment be promptly returned to the appropriate person or payer.
If a patient pays more than they are required to, the patient must be notified as soon as the overpayment is discovered. The practice has a couple of options on how to handle the overpayment, but the provider cannot legally hold on to the money indefinitely.
Let’s say a patient came in for an office visit and paid a co-pay. During the encounter, the provider ended up removing a mole, which is considered surgery and doesn’t require a co-pay. That tuned the co-pay into an overpayment.
Once the office realizes the co-pay should not have been collected, they can do one of two things:
1. Notify the patient of the overpayment. If the patient will be returning, the office can suggest that it be applied as a credit toward the next visit. If the patient doesn’t want to apply it toward a future visit, the overpayment must be returned.
2. Immediately send the patient a check for the overpaid amount with a note explaining the overpayment.
In any case, a provider cannot just keep the overpayment – that is illegal.
If an insurance carrier pays more than expected, it is important to first determine if it is truly an overpayment. Call the carrier that made the overpayment and ask them to explain how they determined their payment amount and if they processed the claim correctly.
If the payer confirms that they did make an overpayment, they should reprocess the claim to show correct payment and send a request for the provider to return the overpayment.
Sometimes the payer will just ask the provider over the phone to return the overpayment. Personally, I always ask them to request the money back with a written explanation.
When you receive the written request for the overpayment, attach a check for the overpayment to the request and send it to the address indicated on the request. If they don’t provide an address, send it to the claims department address but indicate “Attn: Overpayments” on the envelope.
If you receive a payment from an insurance carrier and the entire payment is wrong or not rightfully due to the provider, write “void” on the check and return it to the insurance carrier with an explanation of why the payment was not due. For example, if the payment is for a patient that was not seen by the provider, write “void” on the check and attach a note saying, “This patient was not seen in our office.”
When It’s Not an Overpayment
If the payer states during the call that they processed the claim correctly and there was no overpayment, then you need to investigate further.
Sometimes a patient has two insurance plans. The primary allows a certain amount, makes payment, then the secondary insurance processes the claim. A credit balance results when the secondary payer allows and pays a higher amount than the primary insurance carrier.
This credit balance is not actually an overpayment. The amount contractually adjusted off from the primary insurance carrier was more than needed, based on the secondary insurance carrier’s payment. Therefore, there is not a true overpayment and no money needs to be returned. The patient’s balance just needs to be adjusted to offset the credit.
Sometimes a patient’s secondary insurance carrier is a privately purchased insurance. They do not always follow the same guidelines as other insurance carriers. Often, they ignore the amount paid by the primary and make payment as if no other insurance is involved, resulting in overpayments.
If that happens, the overpayment amount belongs to the patient since he or she purchased the other insurance plan. Again, the provider cannot just keep the money. The provider cannot collect more than was billed out for services.
It is important that possible overpayments are never ignored. Always follow these steps: determine if it is a true overpayment, determine who the overpayment needs to be returned to, then do what is necessary to return it.
And remember: only credit overpayment amounts to future visit charges if you have the patient’s permission.
How does your practice handle overpayments?
Alice Scott and Michele Redmond are medical billing experts, co-owners of Solutions Medical Billing Inc in Rome, N Y., and coauthors of 15 books on medical billing and medical credentialing. Their newest title is Advanced Medical Billing Marketing for the New Economy.
This mother-and-daughter team maintains two medical billing websites, a free newsletter and an active forum. Alice and Michele are on the editorial staff of BC Advantage and are regular contributors to the magazine. Their books are available at www.medicalbillinglive.com.