BC Advantage - 2011 Issue 10

Retroactive Adverse Benefit Determinations

Consider the following scenario. You provide treatment to your patient. Your billing department submits a claim to the insurance carrier, and the carrier pays the claim. Your billing staff applies the insurance payment and invoices the patient for his/her respective portion. Your patient pays the invoice and your billing staff closes out the account for that encounter. Then, a letter from the insurance carrier arrives in the mail.  After all of the this, the insurance carrier demands repayment on the claims they initially determined to be valid.  To make matters worse, the insurance carrier may have already...

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