Recoupment Audits

Edited: Gerald Stevens DC, MS, MPH

It has come to the attention of NYSCA that some members have received requests from insurance companies for over-payment recoupment audits involving claims that were processed several years ago. These recovery efforts may be due to claims processing errors, fee schedule issues or changes in services allowed under the patients' policy.

You should know that due to NYSCA's legislative efforts effective January 1,2007 New York State Insurance law 3224-b(b) was passed that establishes a maximum time limit on attempts by a "health plan" to recoup over-payments from physicians. A health plan shall not initiate over-payment recovery efforts more than twenty-four months after the original payment was received by a physician. The 24 month look back does not apply to over-payment recovery efforts that are:

  1. Based on a reasonable belief of fraud or other intentional misconduct, or abusive billing,
  2. Required by, or initiated at the request of, a self-insured plan, or
  3. Required or authorized by a state or federal government program or coverage that is provided by this state or a municipality thereof to its respective employees, retirees or members.  

The NYSCA is asking that any member who receives one of these recoupment letters to please be diligent in responding to the health plan, and if questions exist to contact the NYSCA insurance committee.


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