It is not unusual for a provider to receive a request from a managed care company attempting to take back what they have already reimbursed on a claim. This is usually due to an audit and frequently their requests are valid. However, there are occasions where this refund demand is related to a payment for a patient the insurer now says was ineligible for benefits at the time the services were rendered even though they had previously verified active coverage. Many providers will assume that they are automatically obligated to pay the money back. Before you do this, check the date of the payment on the Explanation of Benefits. If the payors request for recoupment is more than one year after the date of the payment of the claim, they are prohibited from recouping the reimbursement. Take immediate action and respond that you are denying their untimely request for repayment and cite Florida Statute §627.6131(11) in your letter. The statute states “A health insurer may not retroactively deny a claim because of insured ineligibility more than 1 year after the date of payment of the claim.” Do not send back what is rightfully yours.
