Recoup d'etat: Fighting recoupment efforts

Doctors are complaining that health plans are becoming more aggressive about demanding refunds after claiming that they've overpaid. Experts say physicians can become more aggressive about fighting back.

By Bob Cook, AMNews staff. June 20, 2005.

In the earliest days of elementary school, you learn the rule, "No takebacks!" That means, once you've made a deal, such as trading your lunch, you can't undo what's been done. It's a lesson many physicians believe health plans haven't learned.

Unlike in elementary school, takebacks by health plans have a more genteel name -- "recoupments." Those are funds that health plans paid to doctors but then demanded back after the plan determined, for whatever reason, it paid out in error. There's no study detailing exactly how often plans are demanding recoupment -- or how much they're demanding -- but there's agreement that it's getting to be more often, and for much more money. Medical associations, including the AMA, say private health plan recoupment is an increasing source of complaints from physicians.

Plans say recoupments are fair because physicians who are paid more than a contract dictates have no right to keep the extra money. Physicians respond that because their contracts have no listed fee schedules, or terms saying the plan can change the payment schedule at any time, getting the payment right is the plan's problem.

Also, they wonder how a plan can come back two or three years after the fact to demand recoupment. AMA policy states a plan shouldn't attempt a recoupment more than a year after making a reimbursement, but can attempt one within the same amount of time permitted for submission of the claim, or one year, whichever is less.

Physician fights over recoupments are getting more public. For example, in August, a lawsuit is scheduled to go to trial involving $15 million in recoupments Horizon Blue Cross Blue Shield of New Jersey is seeking from cardiologists in that state. The lawsuit was filed by the New Jersey chapter of the American College of Cardiology and the Medical Society of New Jersey.