Refunds to Insurance Plans

December 6, 2017

Insurance companies occasionally request refunds from dental practices for various reasons, including overpayments on patient claims or retroactive determinations of patient ineligibility for coverage.

Overpayments on patient claims

Sometimes, insurance companies request refunds when they overpay for treatments and services provided to their beneficiaries. This may result from a billing error on the part of the dental office. For example, a practice might submit an incorrect CDT code, leading to overbilling for a service the patient did not receive. In some cases, the insurance company may deduct the overpaid amount from future payments to the dentist, rather than issuing a refund request. This process, known as an offset, can often create confusion when reconciling patient accounts. To help prevent such issues, ensure that the correct CDT code is used when submitting claims.

Termination of coverage

Insurance companies also request refunds after providing coverage to patients who are no longer insured with them. Patients or their employer may have changed their plans without informing their insurance companies and dental providers. In some instances, employees terminated from their job with a self-funded health plan may still receive coverage if they buy continuation coverage, commonly referred to as COBRA.

When a plan administrator requests a refund from a dentist after covering services for ineligible patients, the dentist can ask that they seek it directly from the patient. To support this, patients should receive a clearly stated financial agreement prior to treatment, outlining their responsibility for payment if their insurance plan does not cover the service or later seeks a refund.

To avoid refund requests from insurance companies, dental practices should verify patients’ coverage before treatment and minimize billing errors. At eAssist, our Success Consultants are experts in both dental billing and insurance verification. Consider partnering with us to avoid costly insurance refund requests. To learn more, schedule a consultation today.