Defense of Refund Requests and Offsets

works with medical providers who have provided valuable medical services, submitted claims and received payment, and then received demands for a refund of the payments freely and voluntarily paid by the insurance companies. TGF takes an aggressive approach to these burdensome requests—in almost all circumstances, providers are entitled to keep funds voluntarily paid by private parties. Refund requests are created by decisions or errors made by the payer. When a payer creates the problem, the provider is entitled to keep the payment unless that will result in the provider receiving more than the contractual amount for the services provided. State laws as well as general laws of restitution allow providers who render services and bill appropriately without misrepresentation to keep voluntary payments received from payers.

In contractual situations, the refund request is complicated by the payer’s ability to offset the amount of the refund against future amounts due to the provider. TGF works swiftly and convincingly to halt offsets until the dispute can be resolved. Offsets wreak havoc on accounting systems and require aggressive defense to avoid both lost revenue and increased accounting costs.

Refund requests may be made for a wide array of reasons. The most common reasons for refund requests are set out and discussed in further detail under the billing denial heading.

  • TGF routinely fights refund demands and protects providers’ rights to keep money voluntarily paid by insurers and GHPs
  • Often, refund requests and recoupment activities are based on illegal or incorrect retro-denials—TGF can persuade payers that requests are wrong and obtain retractions or cessation of collection efforts
  • Even when a payer had a legitimate reason to deny the claim at the time of payment, the provider is usually entitled to keep the voluntary payments under laws of restitution and equity
  • Recoupments create accounting nightmares that cost providers time and money to decipher—TGF works to prevent recoupments before they happen and enforce providers’ rights to avoid these expensive consequences