Overpayment Recovery UNDERSTAND AND AUTOMATE THE PROCESS Published with permission of the American Medical Association (AMA) one likes to lose money – whether you are a health insurer or healthcare provider. That’s why it’s critical for physician practices to review and ensure the validity of overpayment recovery notices. If a practice was in fact overpaid, the HIPAA-mandated standard electronic remittance advice (ERA) transaction can simplify the overpayment recovery process, increase efficiency, and ultimately save practices time and money. The American Medical Association (AMA) offers tools to help physician practices navigate the challenges of overpayment recovery and maximize payment automation. the Basics You need to Know an overpayment recovery request is a health plan’s proposed retroactive denial of a previously paid claim. If a physician does not dispute the request, the health plan will collect the previous payment. Overpayment recovery requests can involve individual claims, claim line items, or multiple claims, in the case of global audits. Overpayment recovery is often a manual, tedious process for physician practices. many states have laws that require paper notification of overpayment recovery be mailed to the provider 30 to 90 days prior to the actual recoupment of funds. This notification identifies the claim, the changes to the adjudication, the balance due to the health insurer, any other required elements from state or federal laws, and the date the health insurer will recoup the funds via the era if no appeal has been filed by that date. Physician practices are encouraged to request detailed information from health plans in order to properly identify and investigate overpayment recovery requests. If the practice determines that the request is erroneous, an appeal should be filed. Conversely, if the practice validates the overpayment, the balance due may be remitted via a check to the health plan within the specified time period. If the practice does not send a check to the health plan, the funds will be recouped from a future claims payment’s era. Help practices Automate and improve the process due to the potential involvement of both past and future claims payments, tracking and reconciling overpayment recovery requests can be challenging and complicated. The ama offers an Overpayment recovery Toolkit (www.ama-assn.org/go/overpayment) to help practices understand, automate, and simplify the process. This resource offers a primer on the subject, including common reasons for overpayment recovery, key characteristics of requests, steps to take when addressing overpayment recovery notices, and tips for minimizing future health plan overpayments and recoupments. The toolkit next details how practices can use their practice management system’s era functionality to automate overpayment recovery. The era can be used to address overpayment recovery requests in a more timely and efficient manner by providing faster: • notification of pending overpayment recovery requests from a payor; • notification of overpayment recovery amounts recouped from a claim; and/or • confirmation that a practice’s payment for an overpayment recovery request was received. The era allows overpayment recovery requests to be quickly identified, investigated, and validated, which in turn helps physician practices efficiently reconcile patient account ledgers. The ama’s Overpayment recovery Toolkit also addresses practices’ rights related to overpayment recovery and provides support for practices in overpayment request disputes. The resource provides a stepby step process for practices to use in appealing erroneous overpayment requests and includes tracking and documentation tips. Practices can take advantage of the toolkit’s sample appeal letter when disputing overpayment recoveries. The AMA offers a variety of other tools to assist physicians and their billing partners in electronic transaction implementation. Visit the AMA Administrative Simplification Initiatives website at www.amaassn. org/go/simplify for additional information and resources. no THe jOurNaL OF THe HeaLTHCare BILLINg aNd maNagemeNT assOCIaTION 29
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