Can an Insurance Company Request Refunds?
If the insurance company has made a processing mistake that can be verified the answer is YES!
Many PPO contracts have in the fine print that a dentist must reimburse any amount requested by the payer, even if the error is the insurance company alone. The responsibility for discovering and correcting the payers error and returning the overpayment is placed on the provider. Under these plans the provider usually has 90 days to discover the error and make the appropriate correction otherwise there could be negative consequences. Some of these negative consequences include subtracting money from your next insurance check to cover the loss. This can be from a patient that is not related to the patient where the error happened.
As unfair as it sounds the payers can ask for refunds that go back years—usually up to six years– the statute of limitations will be found in each state insurance laws.
Can the PPO tell me what I can or cannot charge a patient?
The PPO can tell you what a patient can be charged for a service too if it is a certain type of insurance plan and that plan is covered by state law. This is even if the procedure is not covered by the plan. Insured plans for individuals and small business are governed by state law but self-funded (larger employers) are governed by federal law. It is important to know the difference. If the insured plan and the state has a non-covered services law, then the PPO cannot tell you what you can charge for a service. If you are in a state without non-covered laws, then the PPO can tell you what you can charge. The same is true for self-funded ERISA plans.
It is important to know the laws for non-covered services in your state