Refunds to Insurance Plans
Sometimes, insurance companies would ask for refunds from dentists (“Top 10 Claim Concerns: ADA, NADP Share Views on Dentists’ Concerns” 2008). Unfortunately, for insurance companies, “events and state laws often conspire to further delay when the carrier can legally request the refund – a circumstance that forces the process to take far longer than anyone would like” (“Top 10 Claim Concerns: ADA, NADP Share Views on Dentists’ Concerns” 2008). Insurance companies request refunds for several reasons, such as overpayments on patients’ bills and patient ineligibility for their plan.
Insurance companies ask for refunds when they overpay their beneficiary’s treatments and services. According to Greg Alterton, “CDA Benefit Plan Specialist,” “Refund demands always stem from perceived overpayments – the plan paid something it shouldn’t have paid. Overpayments may come from a billing error on the part of the dental office” (2015). For instance, a dental clinic may send the wrong CDT code, overbilling the insurance company for a service the patient did not receive (“Top 10 Claim Concerns: ADA, NADP Share Views on Dentists’ Concerns” 2008). Instead of a refund, “[in] most instances, the overpaid amount is deducted from future benefits paid to the dentist. In some cases, overpayments made to other dentists for the same patient may be deducted from future benefits payments to the dentist” (“Top 10 Claim Concerns: ADA, NADP Share Views on Dentists’ Concerns” 2008).
Insurance companies also want refunds after providing coverage to patients not in their plans anymore (“Top 10 Claim Concerns: ADA, NADP Share Views on Dentists’ Concerns” 2008). Patients or their employer may have changed their plans and did not inform their insurance companies and dentists about the change (“Top 10 Claim Concerns: ADA, NADP Share Views on Dentists’ Concerns” 2008). Regarding employees terminated from their job with a self-funded health plan, they can still receive coverage if they “reimburse the employer for either premiums paid or claim payments” or buy “continuation coverage” (“Responding to dental plans’ retroactive refund demands” 2017). When a plan administrator asks for refunds from dentists after providing coverage for these ineligible patients, dentists could appeal to the plan administrator, “pointing out the federal rule option to seek reimbursement from the employee” (“Responding to dental plans’ retroactive refund demands” 2017). If the plan administrator cannot receive the refund from the employee in the form of “reimbursement claim payments” or payments for continuation coverage, he or she “will again ask for a refund from the employer,” who “would need to recover from the patient” (“Responding to dental plans’ retroactive refund demands” 2017). Patients should receive “[a] properly constructed financial agreement” before undergoing treatment because it lets them know their “responsibility for payment,” “if for any reason her plan doesn’t pay for treatment, or the plan sought a refund for payment” (“Responding to dental plans’ retroactive refund demands” 2017).
Knowing these reasons for refund requests from insurance companies, dental clinics should avoid overbilling insurance companies and verify patients’ insurance and benefits.
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