Addressing claims payment issues can be complicated, but ensuring proper processing and payment of health care claims is vital to the financial health of a practice. The AMA offers resources to help physicians secure correct claims payment from health plans, navigate the overpayment recovery process and appeal incorrect payments.
Overpayment Recovery Toolkit
Attempting to determine the validity of alleged overpayments can divert significant time from direct patient care, resulting in lost practice revenue. Overpayment demands may be made in very general terms and can be intimidating. However, it is critical for practices to effectively and efficiently address overpayment recovery requests.
To help physicians understand health insurer overpayment recovery requests, the AMA created the Overpayment Recovery Toolkit (PDF, members only), which consists of the following resources:
- Recognizing and Interpreting Overpayment Recovery Requests (PDF, members only): Designed to help physicians understand the basics of the overpayment recovery request process, this resource details the reasons that practices may receive overpayment recovery requests, the content of those requests and important information on what to look for in these notifications.
- Addressing and Resolving Overpayment Recovery Requests (PDF, members only): This resource provides guidance to practices on how to investigate and take action when receiving an overpayment recovery request. Additionally, the AMA offers a Sample Claim Overpayment Appeal Letter (DOC, sign-in required) template for practices to utilize.
- Automating the Overpayment Recovery Process (PDF, members only): To help physicians save time and money, this resource explains how practices can automate the overpayment recovery process through use of standard electronic transactions mandated by the Health Insurance Portability and Accountability Act (HIPAA). Additional information on this topic is available in "Get Overpayments Off Your Back with Practice Automation," a webinar designed to provide information on how to effectively address overpayment recovery requests.
- Knowing Your Overpayment Recovery Rights (PDF, members only): This resource offers information on the responsibilities of health plans and the rights of physicians provided by many states laws and regulations. It is intended to ensure that physicians understand their rights in the overpayment recovery request process.
Appealing Claims Payment Issues
Physicians generally collect the majority of their revenue from health insurers. To maximize revenue and maintain financial viability, practices need to ensure that health insurers are properly adjudicating their claims and should be prepared to address/appeal any improper health insurer payment adjustments. To help physicians understand and enact efficient appeals processes, the AMA has created the following informational resource and sample appeal letters:
Identifying and Appealing Health Insurance Claim Payment Issues (PDF, members only) helps physicians implement an effective and efficient claims review/appeals process:
Sample Appeals Letters
AMA members can download these sample letters and customize them in their practices.