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Q/A: Two Payers Both Paid the Claim. Who Gets the Refund?
Published May 13, 2019
By Wyn Staheli, Director of Research
We have a personal injury situation where we submitted a claim was sent to the patient's auto policy carrier who refused payment. We then submitted it to her other insurance. Eventually, both companies paid her claims. Her auto paid at full value, and her secondary paid at a reduced rate due to my contract agreement with them. Her account now has a credit balance. What do I do with the overpayment? Do I keep it? Is there a formula for parsing it to refund to the insurance carriers?
First and foremost, you can NOT keep the money. As for who gets the refund, it is essential to determine which policy is the primary policy and what type of secondary policy the patient has. In most cases, you would refund the money to the secondary payer. For example, if the auto policy was primary, keep their payment and then refund the secondary payer for the amount that they paid. Be sure to include a letter along with the refund to explain what happened.
However, be alert to rare occasions when the overpayment could belong to the patient (who paid the secondary premiums without any coordination of benefits). Legally, it all depends upon the terms in the contract. You don't want to send the money to the secondary payer when in fact it should have been sent to the patient.
To avoid this potential problem, we suggest a letter to the secondary payer with a copy to the patient stating: “Both primary and secondary policies have paid and there is now an overpayment, and we assume that it could belong to the patient. If we do not hear from you by (e.g., June 30th, 20__) we will remit the overpayment to the patient.”
The bottom line: Avoid any perception of duplicate billing, misrepresentation or fraud, and at the same do not overlook any amounts due to the patient.
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About This Tool
The Basic Medicare Fee Calculator is a helpful tool which uses Resource Based Relative Value Units (RBRVS) to estimate fees. It is only for educational purposes and should not be used as your only source for fee schedule determinations. The percentages included here should only be used as a reference and should be adjusted to fit your individual needs. Please note that some states, such as Florida, mandate specific percentages of the Medicare Fee as the allowed amount for personal injury or other claims.
Enter your zip code and click on the [Create Fee Worksheet] button. Geographic adjustments will be applied to the displayed Medicare Fee. The Medicare Fee displayed is the Allowed Amount. To find the Medicare limiting charge for non-participating providers, consult your Medicare Administrative Contractor.
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