Overpayment by HMSA

In some cases in which processing errors or filing errors have occurred, a provider will be Reimbursing HMSA to correct an overpayment.

Also, HMSA reserves the right to audit claims and medical records submitted by participating providers to verify the accuracy of benefit payments made on behalf of HMSA members.

Determination of Overpayment

In some instances, it may be necessary for HMSA to determine if benefit overpayments have been made to a participating provider as a result of improperly submitted claims. Improperly submitted claims include, but are not limited to:

• Claims for services not medically or psychologically appropriate for the diagnosis code(s) indicated.
• Claims for services not provided.
• Claims coded at a higher level of service than was provided (i.e., upcoding).

To determine whether overpayments have been made, HMSA begins by reviewing a valid random sampling of claims submitted by the provider. This method is used when large numbers of claims and records must be reviewed to determine benefit overpayments, but a claim-by-claim review is not feasible. HMSA follows the random sampling guidelines developed by the Centers for Medicare & Medicaid Services (CMS). In addition to the sampling, HMSA may request additional patient records from the provider.

Using the valid random samplings, HMSA determines whether the provider's claim submittals are appropriate or demonstrate a pattern of improper billings. Any benefit overpayment amount is calculated by projecting the findings of the valid random sampling to all of the provider's claims or services at issue.

At the time that the provider is notified of any benefit overpayment, he or she will be informed of the specific findings of the claims and medical records reviews. If the provider disagrees with the findings, he or she may appeal HMSA's determination (see Appealing Processed Claims).

HMSA recovers overpayments by deducting the appropriate amount from any future benefit payments that may be due to the provider and reports them as an adjustment on the Report to Provider If no payments are due to the provider, HMSA will issue a Recovery Letter.

Revision History