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Take Back Events Question

John-Debbie Trunk 3 years ago in Billing/Electronic Modules updated by anonymous 3 years ago 8

Good afternoon,

This afternoon I received a remit from UBH PMAP taking back payments as far back as February 2016. I called UBH to inquire the issue. They advised they "just found out" the client had primary insurance, BCBS. My response was, we are beyond timely filing to bill the primary insurance. UBH left us with no recourse or options to bill DOS from February 2016 to May 2016 due to timely filing. I then asked for the Appeals Dept.


My question to the community - What is your success going to the Appeals Dept with this kind of case? Can anyone provide insights to insurance payers having the ability of going this far back recouping payments because "they just found." Shouldn't payers have a timely response to these kinds of events vs recouping payments beyond one year after the fact? Thank you all for your time.


+1

So sorry to hear this, as it has happened to us as well and we were unsuccessful in obtaining full payment from the primary provider who was BCBS, they paid us for 10 days of a 31 day stay, so it may be worth your while to submit the info to BCBS. I was however able to recoup the R & B portion from DHS as we are a TX facility. YES, I agree payers should be responsible for payments they find after the timely filing period.

Hope this helps.

+1

Sorry to hear this, I sent the billed to BCBS and also send the remittance from UBH (recouplement) as a claim attachment. Stating client never informed us of the insurance change and what we thought was primary should of been secondary. I received full payment from BCBS of MN. Hope that helps.

Really! Thank you CPutz! I will go this route. Very helpful. :)

We just experienced something similar. BCBS took back payment on a client because they "just found out" the client had primary insurance through UBH. We are filing the claim to UBH and will Appeal the denial with UBH. Unfortunately, the service billed was a 90837, which requires authorization from UBH. I am also curious if anyone has had luck with Appeals in these situations?

Submit the claim to the correct primary payer. When it denies for untimely filing, submit an appeal and include a copy of the billing history for the claim(s) from your EHR (showing you filed the claim(s) in a timely manner) the original EOB where UBH paid the claim (showing they did so in a timely manner) AND a copy of the remit where they took back the payment. Your letter should state the points that you had no other insurance on file for the patient, and the patient never provided you with any other insurance information, and UBH took back their payment outside of the timely filing window to submit to the primary but you had initially submitted the claim(s) in a timely manner.


Any time I have had to do this, I have gotten my claims paid. Good luck!

Heather,


Thank you for your comments. You are advising to submit the claims to the "correct" primary payer. Submit an appeal and include a copy of the billing history for the claims and the original EOB where UBH paid. Just to clarify, we are submitting the appeal to the primary payer?


We appreciate the support from this community. Thank you for taking time from your busy days.

I consulted with a representative from UBH Appeals Dept. John suggested I called the primary payer to see if we could waive the Timely Filing element. My concern with this is there will be PR involved due to how the BCBS benefits were for 2016. I will need to send the primary EOB to UBH (2ndary) to the claims dept. This event will be denied due to timely filing. How do we bridge this gap between BCBS and UBH since the Appeals Dept and Claims Dept are two separate departments. John said I could send the EOB's from the primary directly to him so he could explain the event to the claims dept bypassing any timely filing issue. I am attempting to create a conversation between both payers to bridge any lack of communication for claims processing. Thank you everyone for your input. Great community!

+1

Timely filing rules DO NOT apply when the claim issue involves "COB".  If you look in your contracts you will see that COB is one of the exempted claim expectations along with fraud, subrogation recovery, etc.  Now most all contracts only allow up to one year to resolve any and all claim issues including COB and those listed above.