The California Department of Managed Health Care ordered the payor to:
• Cease any and all attempts to recover overpayments from providers without identifying, in writing, the claim, patient’s name, date of service and clear explanation of the excess of the amount due.
• Cease any and all attempts to obtain reimbursement for overpayments after 365 days of the date of payment if the payor cannot demonstrate the overpayment was caused in whole or in part by the provider’s false representation.
The new regulation is based on a case in which Blue Cross of California sent letters requesting reimbursement for overpayment. In 535 of its 548 requests, the payor “failed to assert or demonstrate a factual basis sufficient to show fraud” on part of the provider. In seeking repayment, the payor also failed to identify specifics about the claims, such as the patient, service and date care was rendered.
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