As a result of retro-reviews and audits of coverage decisions conducted by fee-based vendors, many providers are receiving requests from managed care organizations to send back the reimbursement on previously paid claims because those claims have now been deemed to be overpaid. It is critically important for you to become familiar with the Florida statute that outlines the parameters governing these requests for recoupment.

Florida Statute §641.3155 specifically provides for the window of time when, after performing a retroactive review or audit, an HMO may send a request to a provider for a refund due to an overpayment.

Generally, the request must be made to the provider within 30 months after the payor’s payment of the claim, however, if the provider is a licensed medical doctor, osteopathic physician, chiropractor, podiatrist, or dentist, the demand for recoupment must be made within 12 months of the payment of the claim. For the purposes of this statute, the “payment of the claim” date is defined as the date the payment was mailed or electronically transmitted. These time frames do not apply, however, if the carrier’s determination of overpayment is related to a determination of fraud.

Being aware of these limitations will help you discern untimely requests for recoupment.