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February 17, 2020

It’s that time of year again! In this article Dr. Joan Monaco answers your questions related to "overpayment recovery requests."

Tis the season for overpayment recovery.

Have you ever verified eligibility , received the breakdown of benefits and then provided treatment based on the fact that your patient had coverage and available benefits……only to receive a letter months later telling you that the patient was not actually “covered” at the time the service was provided and they want their money back?  Frustrating?  I bet.

Well, the reality is that most insurance carriers have a lag time in updating their systems.  Yes, they do sometimes claim you can access patient information in “real time” …however, real time doesn’t always equate to “up to date”.  Typically, the information you receive is at least a month old.

Why does this happen? Well, employers have the responsibility to report new hires or fires/retirees that left the company to their respective insurance carriers that handle their benefits. Most of the time Human Resources has to “process” the information and then it gets sent off to the insurance carrier who then has to “upload” and “update” their systems. These things take time and unfortunately, we and the patients rely on this information to decide whether they want to go ahead with treatment or not. This delay in updating information quickly creates inconsistencies with the verification information you receive. Of course, you will hear via phone that “this is not a guarantee of coverage” you will also see that in writing. That much is the TRUTH. It’s not a guarantee of anything; but in most cases a necessary chore you must provide for your patients in order to best advise them of their potential financial responsibility.  There are some insurance carriers that suggest you verify eligibility on every patient at every appointment…. that is an arduous task but again something you must consider if participation is something you opt in for.

If you receive a request for refund what should you do?

There are a few questions you should ask yourself.

#1. Does the dentist have a participation contract with the insurance company that is requesting payments be returned?

If the answer is “yes” ….go no further.

This means that by signing your participation agreement you have already agreed in advance to return payments to the insurance carrier upon request.

Do not pass go, do not collect your $100.00……instead you get the “go to jail card” and have to return the monies no questions asked. Of course, you can now go back to your patients and collect the full payment from them……good luck with that!

If you are not in network with the insurance carrier making the request, you need to ask yourself some additional questions…

#2. Was the payment made solely due to the plan’s mistake, without having been induced by a misrepresentation of the dentist?

#3. Did the dentist act in good faith and accept the plan’s payment without knowing a mistake was made?

#4. Was the amount of payment less than or equal to the patient’s liability to the dentist?

If you answered “YES” to questions 2,3 and 4 then you may be able to legally decline to return these payments. 

If you feel that you are being inappropriately asked to return monies, contact NJDA’s Department of Dental Benefits for more information.


Dr. Joan Monaco will be presenting on the Dental/Medical Integration on the following dates:
  • Thursday, March 19: Wall, NJ | 9AM - 12PM |
  • Wednesday, June 24: Mt. Laurel, NJ | 9AM - 12PM
Click here to register