The dreaded takeback, clawback or otherwise known as overpayment recovery is an unwelcomed request to receive from an insurance provider. For a variety of possible reasons, the insurance payor believes that they have overpaid a medical provider for claims submitted, and now the insurance company is requesting a refund.
Physicians and other health professionals may feel that it is easier to simply pay the insurance provider, versus challenging the payor with an appeal. However, successfully appealing takebacks is possible without having to spend an unreasonable amount of work. At ABCS RCM, we have discovered that the more organized and persistent a medical practice is, the better chance they have of winning their appeal.
In order to file a successful appeal with the insurance providers, healthcare practices need to follow these three basic steps.
 Exact Takeback Policy and Contract Language:
Know the exact appeals process for the insurance company requesting the takeback. In general, it is the same principle, but every insurance provider and medical specialty is slightly different in their policies and regulations.
Healthcare professionals should check the language in their insurance contract. What they believe was negotiated into their contracts, versus what is actually printed is sometimes different. Regardless of the insurance provider and contract language, every appeal request should include the following information:
- A statement that acknowledges that there is a charge of alleged overpayment and that a takeback request has been filed.
- The contact information of the health professional who is tracking the appeal.
- The patient’s demographic information including but not limited to the claim number, member ID and dates of service.
- An explanation about the appeal with documentation as well as any insurance provider policies that support the request for an appeal.
 Know the State Insurance Regulations:
Every date is different in how they require insurance companies to perform takebacks for overpayment. Most of the time, there is a limited window of time that allows insurance payors to file a takeback request. For example, in the state of Ohio, insurance law requires third-party payers to:
“ Inform providers about supporting medical documentation that is routinely required for a particular service. A description of the supporting documentation must be available to providers in a readily accessible format.  Establish a claim status check system by which providers and beneficiaries may determine the status of a particular claim.  Automatically pay interest on claims that are not paid in accordance with the timeframes in Ohio’s prompt pay law. The interest rate is eighteen percent annually.  Provide requests for supporting documentation in writing if requested.”
Ohio regulations state that for adjustments (takebacks) to previously paid claims, insurance payors have two years from the date of the payment in question to request a takeback. Here is the exact language:
“Claim payments that are made on or after July 24, 2002, are deemed final two years after the payment is made. After that date, the amount of the payment is not subject to adjustment, except in the case of fraud by the provider. A third-party payer may recover the amount of any part of a payment that the third-party payer determines to be an overpayment if the recovery process is initiated not later than two years after the payment was made to the provider.”
Though many states have similar laws, every healthcare provider should know their state’s precise statutes relating to this topic. In the field of behavioral health, Dr. Jim Broyles, the Director of Professional Affairs for Ohio Psychological Association, recently wrote an article about takebacks or the adjustments of previously paid claims.
 Respond in a quick and organized manner with one designated contact person:
A medical practice needs to actively address any alleged overpayments, even though the investigation may take time and resources away from direct patient care. Healthcare providers need to explore whether this is a one-time occurrence, or is there a larger problem.
The AMA (American Medical Association) recommends that all physicians accurately record and track their communications with insurance payors. These records should include names, takeback requests information as well as appeal attempts and outcomes. To make this process easier, the AMA has even included “Tools for Overpayment Recovery & Claims Appeals” on their website. However, there “Overpayment Recovery Toolkit” is only available to AMA members.
Insurance companies are often very large in scale, which means files and request are sometimes miscommunicated or lost. If a healthcare provider does not understand or feels that information is missing, they should promptly ask for clarification from the insurance payor. Phone calls and emails are quick and convenient but something in writing sent via certified letter is the best option. Emails are sometimes not received, but certified mail provides proof of delivery.
Ideally, communication should leave a clear paper trail so both parties have a clear record in writing. In order to minimize confusion, one person should track the appeal throughout the process.
Open hostility and poor behavior will not convince an insurance payor to reverse the request for an adjustment of a previously paid claim. A level and rational approach are what will successfully move this process forward. Of course, the best way to win a battle is too not have the battle.
This means that a medical billing department or healthcare revenue cycle management service needs to actively manage all submitted and rendered insurance claims. A good claims management & denial system will greatly reduce (or eliminate) the amount of takeback request.
If you have additional questions about insurance company takebacks, payment adjustments and general strategies that healthcare providers can employ to prevent this occurrence – contact us.
Takeback Requests, Successfully Appealing Insurance Takebacks, Clawbacks