the!chiropracticaudit emergency!kit!strategicdc.com/.../2015/11/audit-emergency-kit-2016.pdf ·...

The Strategic Chiropractor, LLC www.strategicdc.com Tel: (800) 577-‐0321

The Chiropractic Audit Emergency Kit


About Tom Necela, DC, CPC, CPMA, CCP-‐P

Dr. Tom Necela founded The Strategic Chiropractor to help DC’s enjoy better profitability, better

income and more freedom both in and out of practice.

Rather than just assume the typical chiropractic practice management route of focusing on stale

marketing tactics to attract new patients, robotic scripts and cookie cutter solutions, Dr. Necela

empowers his coaching clients, seminar attendees and readers to apply strategic thinking, fresh

“Chiropractic 3.0” ideas and a work smarter approach to their practice.

The results have earned Dr. Necela a devoted following of raving clients, waves of repeat seminar

attendees, and over 20,000 blog readers from around the world who are attracted to his unique,

straightforward practical advice.

Dr. Necela’s Background

Dr. Necela is the first chiropractor to ever to achieve Certified Professional Medical Auditor

(CPMA) status, which combined with his background as a former insurance claims analyst and his

certifications as a professional coder (CPC) and professional compliance officer (CCP-‐P), give him a

unique perspective on many of the insurance-‐based challenges chiropractors face today.

For nearly two decades, Dr. Necela’s wit and wisdom has been featured in the biggest chiropractic

publications such as Dynamic Chiropractic,DC Practice Insights, Chiropractic Economics and Today’s

Chiropractic Lifestyle. He’s also been a contributing editor to the ChiroCodeDeskbook and

ChiroCode’s Hot Topics Newsletter as well as author of numerous books and audio products that

serve the chiropractic profession.


How to Handle Medicare Audits, Documentation Requests & Post-‐Payment Demands

Since Medicare is a federal entity with potentially big fines (and a monstrously large audit department), it’s essential that you handle all Medicare requests with special care.

Regardless of whether it’s an audit, a request for additional documentation or a post-‐payment demand for one patient or many, big dollar amounts or small – here’s what to do:

1. Respond to ANY Medicare documentation requests promptly – You may think your notes are bad, but it’s an automatic failure if you don’t send them in and this pretty much guarantees you a ticket for a future audit. Sadly, most chiropractors don’t heed this advice and seal their fate. Send in whatever Medicare is requesting before the deadline. If you have extenuating circumstances that prevent you from getting things in on time, state that in a letter – and then get the requested materials to them ASAP.

2. Make Sure Your Signatures are Present – one of the easiest ways to fail an audit is due to a lack of a signature (or an illegible signature) which verifies that you performed the services you rendered. If, for some reason, your signature is not present on each and every daily note, then the next best thing to do is to complete an Attestation Statement that essentially states, in writing, that you performed the services and the documentation is yours. This will at least get you out of the “low hanging fruit” department and force the Medicare auditors to find something else to pick on with your billing, coding or documentation. Click the link below for a sample Attestation Statement for Medicare.

Medicare Attestation Statement http://bit.ly/1X9pCFk


3. Send in Requested Documentation by Certified Mail – or use some other form of guaranteeing that your requested info has been received. After all, it is Medicare that you are dealing with. Proof that you sent things in helps avoid further problems.

4. No News Is Good News: expect to hear something back from Medicare in approximately 30-‐60 days…if it’s bad news. Generally speaking, if you don’t hear anything after 90 days, it’s good news. And no, Medicare won’t send you an audit “seal of approval” stating that you passed – but they won’t demand their money back either ☺

5. Expect to Be Audited and Be Prepared to Appeal – the bad news is that chiropractors continually are getting a bad rep in Medicare for our billing practices, so it should not cause you great surprise when you are audited. The good news is that the recent OIG report found that 2% of the chiropractors are causing approximately 50% of the problems. So, be prepared to appeal and defend yourself that you are not in that group.

6. Appeal Accurately – Unfortunately, a Medicare appeal is not the same as the appeals process for other payers. You can’t just send in a letter stating that you disagree with their findings and expect (a) that they read it and (b) that they overturn the audit. Believe it or not, each level of appeal has different people to appeal to, different qualifications of who can appeal (and how much money needs to be at stake). Of course, each appeal level also requires its own set of forms and is sent to its own separate department. The proper Medicare appeal levels work as follows:

• Redetermination -‐ First Level Appeal • Reconsideration -‐ Second Level Appeal • Administrative Law Judge – Third Level Appeal

For specific details for each Appeal level, see the following resource:

Medicare Appeals Process http://go.cms.gov/1MnWZS4


7. Get Help: There is a chain of unfortunate events that I see routinely happen in chiropractic audits, especially from Medicare. The first is procrastination. The chiropractor hopes that the issue will go away or they freeze when they think about the possibility of being audited. Don’t make this mistake – act promptly and if you are unsure what to do or why you are being audited, get help quickly. The second unfortunate thing that happens is that worry sets in. If the chiropractor loses the audit and is forced to repay money or if they are not confident that they could pass another one, their confidence in what they are doing begins to erode. This leads to a third wave of misfortune which takes the form of a loss of focus. The chiropractor who is constantly looking over his or her shoulder wondering when the next audit will come simply cannot propel their practice forward at the same time. They become a bit distracted with the fear of another audit looming in their future or they become discouraged by the dollars that they have to repay. In some cases, extreme levels of fear and paranoia can take over and the chiropractor can become completely deflated and want to quit practice. Before this happens to you, listen to my advice: Stop. And. Get. Help. Now. You may literally be one phone call away from confidence, peace, understanding or a plan to handle your audit issue. You don’t have to go through this alone and you certainly don’t want to “wing it” through what can potentially become a devastating moment for your practice, your business and even your life. Fortunately, there’s experienced assistance that’s prepared to get you through this tough time.

Get Chiropractic Audit Help http://www.strategicdc.com/get-‐audit-‐help/


If you are going through an audit, have a post-‐payment demand letter in hand or have received a documentation request or what appears to be an “audit notice” from Medicare (or any other payer), click the link above and get help. Now. Don’t take this the wrong way but…I actually hope NOT to talk to you – at least about this stuff ☺ But if you’ve got an audit issue, I’m here and the link to get help is below.

Get Chiropractic Audit Help http://www.strategicdc.com/get-‐audit-‐help/

Best,

Tom Tom Necela, DC,CPC, CPMA, CCP-‐P The Strategic Chiropractor

!

The!Strategic!Chiropractor,!LLC!!!!!!!!!www.strategicdc.com!!!!!!!!!!Tel:!(800)!577>0321!!

!

!

Chiropractic!Audit!Emergency!Checklist!

We#hope#that#you#don’t#have#to#use#this#11#but#if#you#do,#don’t#do#anything#irrational.##Here#is#a#checklist#of#items#to#immediately#consider#when#you#receive#an#audit#letter.#

1. Do!Not!Procrastinate:##Decide#what#you#will#do#in#a#timely#manner.##Too#many#doctors#get#their#audit#letter#and#go#into#paralysis#mode.##It#isn’t#going#away#and#there’s#likely#a#deadline#to#respond.##Things#will#get#worse,#not#better,#if#you#procrastinate#as#you#will#have#fewer#options.##Decide#when#you#will#handle#the#issues#by#and#then…do#it!#

2. Determine!the!Payer’s!Right!to!Audit!You:##As#mentioned#in#my#“What#to#Do#About#Refund#Requests”#article,#a#good#first#step#is#to#determine#whether#or#not#the#payer#has#the#right#to#audit#you.#If#you’re#an#out#of#network#provider,#there#is#a#possibility#that#the#carrier#has#no#legal#recourse#to#audit#you#depending#on#state#laws.##On#the#other#hand#a#governmental#entity#like#Medicare#definitely#can#audit#you,#so#move#on#to#the#next#step.###

3. Determine!exactly!what!the!audit!letter!states.#In#other#words,#can#you#categorize#precisely#what#the#letter#is#asking#for?#Are#they#requesting#a#chart#audit#where#they#want#to#look#at#your#medical#records?##Do#they#want#to#perform#a#on1site#visit#to#your#clinic?##Are#they#auditing#you#based#on#or#with#the#intensions#of#interviewing#a#patient?##Is#this#a#Medicare#CERT#audit#(a#the#random#sampling#audit)?##Or#is#this#a#Medicare#Recovery#Audit#Contractor#audit#11#a#complex#review#where#they’re#going#to#look#at#your#medical#records.##Is#this#a#commercial#payer#who#is#requesting#repayment#because#they#have#already#determined#you#billed,#coded#or#documented#something#improperly?#Or#are#they#just#requesting#a#bunch#of#records#(which#may#lead#to#a#payment#demand)?##Accurately#determining#the#purpose#of#the#letter#is#the#first#step#towards#generating#an#appropriate#response.#

#

!


#

#

4. Determine!If!You!Can!Meet!Audit!Requests.##If#the#time#frame#that#the#carrier#is#requesting#is#not#reasonable#due#to#some#sort#of#extenuating#circumstances,#contact#the#auditor#for#an#extension.#For#example:#if#the#audit#letter#hits#you#at#a#really#“bad”#time#(i.e.##you#are#in#the#middle#of#moving#your#office;#you#are#coming#back#from#2#weeks#vacation#to#find#out#that#you#have#two#days#to#respond,#etc)#then#do#not#be#afraid#to#ask#for#an#extension.##Similarly,#if#your#records#were#destroyed#by#a#flood#in#your#office,#let#them#know#this#promptly.#But#be#prepared#to#give#a#good,#solid#reason#and#proof#for#your#request.##

5. Determine!How!to!Respond!in!a!Timely!Manner.##Once#you’ve#determined#which#type#of#audit#they’re#intending#to#conduct#on#your#practice,#you#need#to#formulate#response#to#that#audit#or#to#the#request#that#the#audit’s#making#in#a#timely#manner.##Here,#you#should#quickly#assemble#a#list#of#steps#that#it#will#take#to#answer#their#request.##For#example:#have#staff#pull#charts#of#individual#patients;#review#payments#that#were#made#for#dates#of#services,#etc.##Have#a#concrete#date#or#time#frame#in#mind#that#you#will#submit#materials#by#or#that#you#will#be#ready#have#to#have#an#auditor#come#to#your#practice.#

6. Make!Sure!Proper!Authorization!Has!Been!Obtained!(OnSSite!Visits!Only).!!Before#you#allow#anyone#to#come#to#your#office#and#view#chart#notes#or#inspect#your#clinic,#make#sure#that#the#auditors#have#the#proper#authorization#to#do#so.#In#other#words,#don’t#ever#permit#someone#to#simply#walk#in#your#practice#and#demand#to#see#files#unless#they#have#an#appointment#verified#in#writing#or#are#accompanied#by#some#law#enforcement#officers.#Either#way,#if#a#payer#wants#to#come#in#your#practice,#you#should#probably#skip#immediately#to#Step#9.!!

7. Put!all!communication!in!writing.#All#communication#to#you#should#be#in#writing#as#well.##Don’t#communicate#with#auditors#via#phone,#fax,#email#or#any#places#where#things#can#get#lost.#Personally,#I#like#the#idea#of#certified#mail#even#both#ways.##Because#then#you#know#the#person#has#it#and#there’s#no#chance#for#misunderstanding.###

!


#

#

8. Is!this!something!for!which!you!will!experienced!assistance?!You#may#need#to#obtain#the#assistance#of#a#certified#professional#coder#or#a#certified#professional#medical#auditor#such#as#myself#to#help#defend#you.##A#healthcare#attorney#may#wise,#especially!if#there#are#several#zeros#in#your#demand#or#repayment#letter.##If#fraud#charges#are#alleged,#get#an#attorney.#

9. Don’t!Panic!#Finally,#one#of#the#single#most#important#things#not#to#do#is#to#panic#in#the#presence#of#an#audit#letter.#Don’t#assume#that#your#documentation#is#substandard.#Don’t#automatically#determine#they#will#find#your#records#insufficient.#And#whatever#you#do,#never#take#matters#into#your#own#hands#and#alter#medical#records.#Do#not#change#the#documentation.###

10. Determine!How!You!Can!Fix!the!Future.!!One#of#the#most#disturbing#aspects#of#dealing#with#an#audit#is#the#possibility#that#whatever#went#wrong#in#the#first#place#can#cause#the#payer#to#come#back#and#audit#you#again.##Here,#it#makes#sense#to#either#address#known#problems#or#get#help#in#identifying#troublesome#patterns.##Certainly,#you#can#appeal#any#repayment#demands#and#many#win.##But#this#is#no#way#to#live#and#grow#a#practice!!

!

Need!Additional!Assistance?!

We#do#offer#strategic#assistance,#advice#and#help#for#chiropractors#who#have#received#an#audit#notification.##See#www.strategicdc.com/services#for#info.#

!

REFUND REQUEST REJECTION LETTER Note:

! Do NOT Use For Medicare Audits or repayment requests. Medicare is a Federal Entity and operates on a different set of regulations.

! If you are a contracted provider, use the entire second sentence (yellow + green) ! If you are NOT a contracted provider, use only the yellow portion of the second sentence ! Remove the highlighting and insert the appropriate info in brackets before sending ☺

[~Current Date~] Attn: Director of Claims [~Insurance Policy #1 Carrier~] [~Insurance Policy #1 Address~] Re: Patient: [~Patient Name~] Policy: [~Insurance Policy #1 Number~] Insured: [~Responsible Party Name~] Dates of Service: [~First Service Date~] - [~Last Service Date~] Amount: [~Total Charges~] Dear Director of Claims, We are in receipt of a refund request regarding the above referenced claim. This letter is to formally appeal your request for repayment based on our contractual rights as an in-network provider for [Insurance company name]. According to our records, the books are closed on this claim and your company many not have legal standing to enforce the refund/recoupment request. According to our review, the claim was paid appropriately and no credit balance is on the account. Further, we have applied all applicable contractual adjustments and have billed the patient for any applicable patient responsibility. It is our position that the legal theory of laches may prohibit your request for repayment. Laches is a legal doctrine which, according to Barron's Law Dictionary, Third Edition, provides protection to a party with an equitable defense in situations where long-neglected rights are sought to be enforced against a party. According to general legal rules, as an innocent creditor, we cannot be held liable for mistakes on the payor's part. We obtained the patient's insurance card provided at the time of service and based on that, believed we were entitled to third party payment from your company. We received the payment and explanation of benefits in good faith, and based on that, did not bill the patient for the portion covered by insurance. We provided services in good faith and the funds received have been exhausted. Now, a reimbursement of the insurance benefit to you would seriously jeopardize our ability to collect the debt from the patient. Further, your company has not provided sufficient documentation to support the request, including a copy of the policy or plan terms, the date the error was detected and by whom and proof that the patient is aware and agrees with the action taken on the policy. We feel that we have been properly reimbursed for services rendered and no refund will be issued. If, in the future, you elect to deduct the alleged overpayment from future benefits to be paid, we reserve the right to consult further legal counsel in order to insure that our full rights, which may or may not be addressed in this letter, are preserved. Please do not hesitate to call me if you have any questions or need additional information. Sincerely,

ww

w.strategicdc.com

Refund R

ecoupment Law

s

State

Statute

Period

Time Lim

it for Seeking R

efund of Overpaid

Claim

A

dditional Factors E

xemptions

ALA

BA

MA

A

l 27-1-17 12

Months

An insurer, health service corporation, and

health benefit plan shall not retroactively seek recoupm

ent or refund of a paid claim after the

expiration of one (1) year from the date the

claim w

as initially paid or after the expiration of the sam

e period of time that the health care

provider is required to submit claim

s, w

hichever date occurs first.

An insurer, health service

corporation, or health benefit plan shall not retroactively seek recoupm

ent or refund of a paid claim

for any reason that relates to the C

OB

of another carrier responsible for the paym

ent of the claim after

expiration of eighteen (18) m

onths from the date claim

w

as paid.

An insurer, health service corporation,

and health benefit plan shall not retroactively seek recoupm

ent or refund of a paid claim

from provider for

any reason, other than fraud or coordination of benefits or for duplicate

payments after the expiration of one

year from the date that the initial claim

w

as paid.

ALA

SKA

A

S 21.54.020

No Lim

it A

healthcare insurer can recover an amount,

wrongly paid to a provider.

None

N/A

AR

KA

NSA

S A

nn. § 23-61-108, §23-63-1806, §25-15-201

18 M

onths A

health care insurer cannot seek refund of paid claim

after the expiration of eighteen (18) m

onths from the date the claim

was initially

paid.

A health care insurer has one

hundred and twenty (120) days

from the date of paym

ent to notify the provider of a

verification error and the fact that services rendered w

ill not be covered if the error w

as m

ade in good faith at the time

of the verification.

Except in cases of fraud com

mitted by

the health care provider, means fraud

that the insurer discovered after the eighteen (18) m

onth period and could not have discovered prior to the end of

the eighteen-month period.

This document is to help you understand that each state has its ow

n laws in term

s of how

far back a payer can go to reclaim their m

oney via a post-payment audit. If

you need additional audit assistance contact us at [email protected]

ww

w.strategicdc.com

Refund R

ecoupment Law

s S

tate S

tatute P

eriod Tim

e Limit for S

eeking Refund of O

verpaid C

laim

Additional Factors

Exem

ptions

AR

IZON

A

§20-3102 12

Months

A health care insurer shall not adjust or

request adjustment of a paym

ent or denial of claim

more than one year after the date

health care insurer has paid the claim. If a

provider and insurer agree through contract about adjustm

ent then even they have sam

e length of time to request adjustm

ent of a claim

. Once claim

is adjusted an insurer or provider shall ow

e no interest on the overpaym

ent or underpayment resulting

from the adjustm

ent as long as the adjustm

ent or recoupment taken w

ithin the period of 30 days of the date of claim

adjustm

ent.

None

This Section shall not apply in case

of fraud.

CA

LIFOR

NIA

110133.66 (2005 C

al A

LS 441;!2005 C

al SB

634; S

tats 2005 ch.44)

12 M

onths R

eimbursem

ent request for the!overpaym

ent of a claim shall not be!m

ade, unless a w

ritten request for!reimbursem

ent is sent to provider w

ithin!365 days of the date of paym

ent on the!overpaid claims.

None

Time lim

it of 365 days shall not apply if the!overpaym

ent was caused in

whole or in part!by fraud or

misrepresentation on the part of!the

provider.

CO

LOR

AD

O

C.R

.S. 10-16-704 (2009)

12 M

onths A

djustments to claim

s by the carrier!shall be m

ade within the tim

e period set!out in contract betw

een the provider and!the carrier. The tim

e period shall be the!same

for the provider and the carrier!and shall not exceed 12 m

onths after the!date of the original explanation of!benefits. If no

contract exists then!adjustments to claim

s shall be m

ade 12!months after the date of

the original!explanation of benefits.

Adjustm

ents to claims related

to!coordination of benefits w

ith!federally funded health benefit!plans, including

medicare and!m

edicaid, shall be m

ade within!thirty-six (36)

months after the!date of

service.

Adjustm

ents to claims m

ade in cases w

here a!carrier has reported fraud or abuse com

mitted!by the provider,

shall not be subject to the!requirem

ents of this subsection.

ww

w.strategicdc.com

Refund R

ecoupment Law

s S

tate S

tatute P

eriod Tim

e Limit for S

eeking Refund of O

verpaid C

laim

Additional Factors

Exem

ptions

CO

NN

ECTIC

UT

SB

764 60

Months

Insurers and HM

Os are prohibited from

!seeking to recover an overpaym

ent for a!claim

paid under a health insurance!policy unless they provides w

ritten!notice to the person from

whom

!recovery is sought within five (5) years!

after receiving the initial claim.

None

None

DELA

WA

RE

None

None

None

None

None

DISTR

ICT O

F C

OLU

MB

IA

D.C

. Code § 31-3133

6 Months

Insurer may only retroactively deny!

reimbursem

ent to provider for services!subject to C

OB

during the 18-month!period after the

date that the health!insurer paid the health care provider; or!during the 6-m

onth period after the date!that the health insurer paid the

health!care provider.

A health insurer that

retroactively!denies reim

bursement to a health!care

provider shall provide a!written

statement specifying the!basis

for the retroactive denial. If!the retroactive denial of!

reimbursem

ent results from

CO

B,!the w

ritten statement

shall!provide the name and

address of!the entity acknow

ledging!responsibility for paym

ent of the!denied claim

.

This section will not apply if inform

ation!subm

itted was fraudulent; or im

properly!coded or duplicate claim

or does not otherw

ise!conform w

ith the contractual obligations. If!insurer retroactively

denies reimbursem

ent for!services as a result of cob the provider shall!have 180 days after the date of denial, unless!the insurer perm

its longer time insurer that!

denies reimbursem

ent to provider shall give!provider a w

ritten notice specifying the basis!for the retroactive denial. This section shall not!apply to an adjustm

ent to reim

bursement!m

ade as an annual contracted reconciliation of!a risk-

sharing arrangement.

FLOR

IDA

FL §627.6131

30 M

onths If an overpaym

ent in result of retroactive!review

or audit of coverage decisions or!paym

ent levels a health insurer must!subm

it the claim

s details to provider!within 30 m

onths after the health!insurer's paym

ent of the claim

A provider m

ust pay, deny, or!contest the claim

for!overpaym

ent within 40 days

after!the receipt of the claim

and must!pay or deny w

ithin 120 days of!the receipt. Failure

to the above!creates an uncontestable!obligation to pay

the claim. The!health insurer

may not reduce!paym

ent to the provider for other!services

unless the provider!agrees to the reduction in w

riting!or fails to respond to the health!

insurer's overpayment claim

.

Time lim

it of 30 months. E

xcept in the case of!fraud com

mitted by the health

care provider

ww

w.strategicdc.com

Refund R

ecoupment Law

s S

tate S

tatute P

eriod Tim

e Limit for S

eeking Refund of O

verpaid C

laim

Additional Factors

Exem

ptions

GEO

RG

IA

O

.C.G

.A. § 33-20A

-62 18

Months

No carrier m

ay conduct a post payment!audit

or impose a retroactive denial of!paym

ent on any claim

that was!subm

itted within 90 days of

the last date!of service or discharge covered by such!claim

unless: (1) notice of intent to!conduct such an audit is provided; (2)!N

ot m

ore than 12 months have elapsed!since the

last date of service or discharge!covered by the claim

; (3) Any such audit!or retroactive

denial of payment m

ust be!completed and

notice provided to the!claimant of refund due

within 18 m

onths!of the last date of service or discharge!covered by such claim

.

No insurance carrier m

ay!conduct a post-paym

ent audit or!im

pose a retroactive denial of!paym

ent on any claim

submitted!after 90 days unless

a written!notice is provided, not

more than!12 m

onths have elapsed and it!should be

finalized within 24!m

onths.

Any such audit m

ust be completed

within 18!m

onths from the date of final

discharge of!claim.

HA

WA

II N

one N

one N

one N

one N

one

IDA

HO

N

one N

one N

one N

one N

one

ILLINO

IS N

one N

one N

one N

one N

one

IND

IAN

A

IC 27-8-5.7-10

24 M

onths Insurance m

ay request the provider to!repay the overpaym

ent or adjust a!subsequent claim

after the expiration of!two years from

the date claim

is paid.

None

This section does not apply in cases of fraud!by the provider, the insured, or

the insurer!with respect to the claim

on w

hich the!overpayment or

underpayment w

as made.

IOW

A

191-15.33 (507B)

24 M

onths Insurance m

ay not audit a claim m

ore than tw

o years after the submission of the claim

to insurer &

not a claim billed for less than

$25.00.

None

The law applies only if the carrier did

not suspect fraud.

KA

NSA

S N

one N

one N

one N

one N

one

KEN

TUC

KY

Y 304-17A

-708 24

Months

An insurer shall not be required to correct a paym

ent error made to a provider if the

provider's request for a payment correction is

filed more than tw

enty-four (24) months after

the date that the provider received payment

for the claim from

the insurer.

None

Time lim

itation shall not be applicable in case of fraud.

ww

w.strategicdc.com

Refund R

ecoupment Law

s S

tate S

tatute P

eriod Tim

e Limit for S

eeking Refund of O

verpaid C

laim

Additional Factors

Exem

ptions

LOU

ISIAN

A

LRS

22:250.38 N

one H

ealth insurance shall provide the healthcare provider w

ritten notification in accordance with

LRS

22:250.38. Healthcare provider shall be

allowed thirty days from

receipt of written

notification of recoupment to appeal the health

insurance issuer's action.

If a healthcare provider disputes insurance's

notification of recoupment and

a contract exists,!the dispute shall be resolved according to term

s of contract.!If no contract exists, the dispute shall be

resolved as any other dispute under C

ivil Code A

rticle 2299 et seq.

None

MA

INE

24-A - §4303.

12 M

onths The tim

e that has elapsed since the date of paym

ent of the previously paid claim does not

exceed 12 months.

None

The retrospective denial of a previously paid claim

may be perm

itted beyond 12 m

onths from the date of paym

ent only if: (1) The claim

was subm

itted fraudulently (2) D

uplicate payment (3)

Services identified in the claim

were not

delivered by the provider (4)!Adjustm

ent w

ith another insurer CO

B 6. The claim

paym

ent is the subject of legal action.

MA

RYLA

ND

M

. A. C

ode section 15-1008 6 6 M

onths A

carrier may only retroactively deny

reimbursem

ent paid to healthcare provider during the six m

onth period after the date the carrier paid the claim

.

This Section P

rovides time

frame for the period of 18

months in case of services

subject to coordination of benefits w

ith another carrier.

The time period is not lim

ited if:!(1) Inform

ation submitted w

as fraudulent.!(2) Im

properly Coded!(3)

Paym

ent was m

ade for duplicate claim.!

(4) a claim subm

itted to MC

O &

the claim

was for services provided to a M

D

Medical A

ssistance Program

recipient during a tim

e period when P

rogram has

permanently retracted the capitation

payment for the P

rogram recipient.!

MA

SSAC

HU

SETTS H

B 976

12 M

onths The tim

e which has elapsed since the date of

payment of the challenged claim

does not exceed 12 m

onths.

None

The retroactive denial of a previously paid claim

may be perm

itted beyond 12 m

onths from the date of paym

ent only if: (1) claim

was subm

itted fraudulently; (2) claim

payment w

as incorrect because the provider or the insured

was already paid; (3) health care

services were not delivered by the

physician/provider.

ww

w.strategicdc.com

Refund R

ecoupment Law

s S

tate S

tatute P

eriod Tim

e Limit for S

eeking Refund of O

verpaid C

laim

Additional Factors

Exem

ptions

MIC

HIG

AN

N

one N

one N

one N

one N

one

MIN

NESO

TA

None

None

None

None

None

MISSISSIPPI

None

None

None

None

None!

MISSO

UR

I S

ec: 376.384 12

Months

Prohibit requesting a refund or offset!against a

claim m

ore than twelve!m

onths after a health carrier has paid.

None

Except in cases of fraud or

misrepresentation!by the health care

provider.

MO

NTA

NA

33-22-150

12 M

onths A

health insurance issuer may not!request

reimbursem

ent or offset another!claim

payment for reim

bursement of an!invalid claim

or overpaym

ent of a claim!m

ore than 12 m

onths after the payment!of an invalid or

overpaid claim.

None

If insurance does not limit the tim

e for!subm

ission of a claim for paym

ent, then!insurance m

ay not request reim

bursement or!offset another claim

paym

ent for!reimbursem

ent of an invalid claim

or!overpayment of a claim

m

ore than 12 months!after the paym

ent of an invalid or overpaid claim

.

NEB

RA

SKA

Title 210 – N

EB

.!D

EP

T OF IN

S.!

Chapter 60 (011-!011.01(B

))

6 Months

011.01(B)(3) The insurer has notified the!

claimant w

ithin six (6) months of!the date of

the error, except that in!instances of error prom

pted by!representations or nondisclosures of

011.01(B)(4) S

uch notice states!clearly the nature of the error!

the amount of the overpaym

ent,!and the three year lim

itation!as provided in subsection

011.01(C)

None

NEVA

DA

N

one N

one N

one N

one N

one

NEW

H

AM

PSHIR

E

Insurance Code 420-J;8-b.

18 M

onths N

o health carrier shall impose on any!health

care provider any retroactive!denial of a previously paid claim

or any!part thereof unless: (a) the carrier has!provided the reason for the retroactive!denial in w

riting to the health care!provider; and (b) the tim

e which has!

elapsed since the date of payment of the!

challenged claim does not exceed 18!m

onths.

None

Time lim

it can be extended belong the period!of 18 m

onths provided claim w

as subm

itted!fraudulently or claim w

as incorrect because!the provider w

as already paid for the services!claim

paym

ent is the subject of adjustment!

with a different insurer.

ww

w.strategicdc.com

Refund R

ecoupment Law

s S

tate S

tatute P

eriod Tim

e Limit for S

eeking Refund of O

verpaid C

laim

Additional Factors

Exem

ptions

NEW

JERSEY

C

.17B:30-48 C

hapter 352 18

Months

No payer shall seek reim

bursement for!

overpayment of a claim

previously paid!pursuant to this section later than 18!m

onths after the date the first paym

ent!on the claim

was m

ade.

No payer shall seek m

ore than!one reim

bursement for!

overpayment of a particular!

claim. A

t the time the!

reimbursem

ent request is!subm

itted to the health care!provider, the payer shall

provide!written docum

entation that!identifies the error m

ade by the!payer in the processing or!

payment of the claim

that justifies!the reim

bursement

request.

Claim

s that were subm

itted fraudulently or!subm

itted by health care providers that have a!pattern of inappropriate billing or claim

s that!were subject to

coordination of benefits.

NEW

MEXIC

O

None

None

None

None

None

NEW

YOR

K

§ 3224-b 24

Months

Prohibit H

MO

s and other insurers from!

demanding refunds from

a physician!more

than two years after the claim

was!initially

paid.

Require 30 days notice to!

providers when the insurer is!

seeking a refund.

This limitation does not apply if it

involve!fraud, intentional misconduct,

abusive billing!or when initiated at the

request of a self!funded plan or required by a federal or state!governm

ent program

.!

NO

RTH

C

AR

OLIN

A

None

None

Depends upon the contractual term

s of a!healthcare provider and insurance.

None

None

NO

RTH

D

AK

OTA

N

one N

one N

one N

one N

one

OH

IO

Revised C

ode 3901.38.8 &

3901.388 24

Months

Third party insurer may recover an!overpaid

amount not later than tw

o year!from the date

the claim w

as paid to the provider. The P

rovider should be informed about the

overpayment practices through notice.

Provider shall have a right to file appeal. In

case of no response from the provider the

carrier is free to initiate recovery practices.

None

Time lim

itation shall not be applicable in case!of fraud.

ww

w.strategicdc.com

Refund R

ecoupment Law

s S

tate S

tatute P

eriod Tim

e Limit for S

eeking Refund of O

verpaid C

laim

Additional Factors

Exem

ptions

OK

LAH

OM

A

§36-1250.5 24

Months

Act of insurance com

pany will be considered

as unfair claim settlem

ent practices act if insurance request refund from

the provider after the period of 24 m

onths from the date

claim w

as paid.

None

This section shall not apply where the

claim w

as submitted fraudulently or

provider otherwise agrees to m

ake a refund of claim

.

OR

EGO

N

None

None

None

None

None

PENN

SYLVAN

IA

None

None

None

None

None

RH

OD

E ISLA

ND

N

one N

one N

one N

one N

one

SOU

TH

CA

RO

LINA

§ 38-59-250 18

Months

An insurance m

ay not initiate!overpayment

recovery process from a!provider m

ore than 18 m

onths after the!initial payment w

as received by the!provider.

An insurer shall initiate any!

overpayment recovery efforts

by!sending a written notice to

the!provider at least 30 business days!prior to engaging

in the!overpayment recovery

efforts.

This time lim

it does not apply to the initiation!of overpaym

ent recovery efforts: (1) based!upon a reasonable

belief of fraud or other!intentional m

isconduct; (2) required by a!selfinsured plan; or (3) required by a state or!federal governm

ent program.

SOU

TH

DA

KO

TA

None

None

None

None

None

TEXAS

§ 3.70-3C

180 Days

The insurer has no later than the 180 day!after provider receives paym

ent to!recover an “overpaym

ent” must provide!w

ritten notice and m

ention specific!reasons for request of recovery of funds.

If carrier as secondary payer pays!a portion of a claim

that should!be paid by the prim

ary carrier,!the secondary payer

may recover!overpaym

ent from

the carrier!that is primarily

responsible for!that amount. If

the portion of the!claim

overpaid by the secondary!payer w

as also paid by the!prim

ary payer, the secondary!payer m

ay recover the amount

of!overpayment from

the physician.

None

ww

w.strategicdc.com

Refund R

ecoupment Law

s S

tate S

tatute P

eriod Tim

e Limit for S

eeking Refund of O

verpaid C

laim

Additional Factors

Exem

ptions

UTA

H

§ 31A-26-301.6

12 M

onths The insurer m

ay recover any amount

improperly paid to a provider or an insured (a)

within 24 m

onths of the amount im

properly paid for a coordination of benefits error; (b) w

ithin12 months of the am

ount improperly

paid for any other reason; or (c) within36

months of the am

ount improperly paid w

hen the im

proper payment w

as due to a recovery by M

edicaid,!Medicare, the C

hildren's Health

Insurance Program

, or any other state or federal health care program

None

None

VERM

ON

T 18 V

.S.A

. § 9418 12

Months

A health plan shall not retrospective!deny a

previously paid claim unless at!least 30 days

notice of any retrospect!denial or overpayment

recovery is!provided inwriting to the provider

or!the time that has elapsed since the date!of

payment of the previously paid claim

!does has exceeded 12 m

onths.

None

The retrospective denial of a previously paid!claim

shall be permitted beyond 12

months if!(1) the plan has a reasonable belief that fraud!or other intentional

misconduct has occurred;!(2) the claim

paym

ent was incorrect because!the

health care provider was already paid;

(3)!health care services identified in the claim

!were not delivered by the

provider; (4) the!claim paym

ent is subject of adjustm

ent with!another

health plan; or (5) the claim is the!

subject of legal action.

VIRG

INIA

§ 38.2-3407.15

12 M

onths C

arrier can only impose retroactive!denial of

claim if provided the reason for!denial,

provider was already paid for the!services and

time period does not exceed!the lesser of 12

months or a num

ber of!days mentioned in a

contract.

None

Exception of fraud is not provided.

ww

w.strategicdc.com

Refund R

ecoupment Law

s S

tate S

tatute P

eriod Tim

e Limit for S

eeking Refund of O

verpaid C

laim

Additional Factors

Exem

ptions

WA

SHIN

GTO

N

Chapter 48.43.600

30 M

onths A

carrier may not request a refund from

!a health care provider of a paym

ent!previously m

ade to satisfy a claim unless!it does so in

writing to the provider!w

ithin thirty months

after the date!that the payment w

as made.

A carrier m

ay not for reasons!related to coordination of

benefits!with another carrier (a)

Request!refund from

a health care!provider; or (b) request

that a!contested refund be paid any!sooner than six m

onths after!receipt of the request. A

ny such request m

ust specify why

the carrier believes the provider ow

es the refund, and include the nam

e and mailing address

of the entity that has primary

responsibility for payment of

the claim.

This Section shall not apply in case of

fraud.

WEST

VIRG

INIA

W

VC

§ 33-45-2 12

Months

Carrier can only deny a claim

where a!

provider was already paid for the!service,

claim w

as not covered under the service and provider not entitled to reim

bursement for the

period of one year from the date w

hen the claim

was paid to the provider.

None

Limitation shall not be applicable in

case of!misrepresentation or fraud by

provider.

WISC

ON

SIN

None

None

None

None

None

WYO

MIN

G

HB

0167!Section 26-15-124

24 M

onths (1) of this subsection is sent by the insurer!

within eighteen (18) m

onths after the!date of paym

ent or twenty-four (24)!m

onths after the date of service,!w

hichever is sooner;!(2) The notice required by paragraph

None

None

© 2014 The Strategic C

hiropractor. Disclaim

er: The information contained in this docum

ent is provided for general educational and informational purposes only

and is believed to be accurate as of the time of its printing. H

owever, this docum

ent should not, under any circumstances, be construed as legal advice.

Furthermore, because state law

s and regulations change frequently, The Strategic C

hiropractor makes no claim

s or warranties as to the accuracy, veracity or

completeness of the inform

ation contained in this spreadsheet and assumes no liability arising there from

. Chiropractors are encouraged to perform

their own due

diligence to ensure that their own state law

s are current. The Strategic C

hiropractor reserves the right to amend, supplem

ent or delete the contents of this spreadsheet or stop publication thereof at any tim

e and without notice. U

se of this document constitutes agreem

ent with these term

s.

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