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Ely
Ely, Counselor at Law
Category: Legal
Satisfied Customers: 87076
Experience:  Private practice with focus on family, criminal, PI, consumer protection, and business consultation.
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I am an acupuncturist in NY, I got a letter from OXford, which

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I am an acupuncturist in NY, I got a letter from OXford, which I got overpayment 1.1M FROM LAST FEW YEARS, they want to pay them back. How I can do now? thanks
Submitted: 1 year ago.
Category: Legal
Expert:  Ely replied 1 year ago.
Hello friend. My name is XXXXX XXXXX welcome to JustAnswer. Please note: (1) this is general information only, not legal advice, and, (2) there may be a slight delay between your follow ups and my replies.

I am sorry for your situation. Can you please clarify:

1) Do you still work for them, or not;
2) By Oxford, what did you mean - which entity, as there are several;
3) Between what years did the over-payment occur, i.e. 1998-2005, for example;
4) How much was the over-payment for - $1.1 million; and
5)this is very important, did you (1) not realize nor reasonably could have realized the over-payment and (2) have you already spent it?

This is not an answer, but an Information Request. I need this information to answer your question. Please reply, so I can answer your question. Thank you in advance.
Customer: replied 1 year ago.


I have done claims for my service of their patients, oxford is medical insurance

 

2009 to 2012

 

they say they did overpayment error, because some my codes which I claimed are not correct. But I explained to them already.

 

I did spent it already

 

The letter said, if I don't response them in 30 days, they will offset my payment for my new claims to them

 

thank you very much

Expert:  Ely replied 1 year ago.
Thank you. Please give me a second while I am typing out your answer...
Expert:  Ely replied 1 year ago.
Thank you for your clarification.

How I can do now?

Well, first we have to understand what they can attempt to do here. They can attempt to sue you.

To sue in a state court, one needs to have a "cause of action." There are numerous causes of action, such as "breach of contract," "negligence," "fraud," "unjust enrichment," etc., as well as causes of action rooted in statutory law. Every state has their own although they are very similar to each other in every state.

Here, with some elements embellished as Plaintiffs always do, they can attempt to sue for (1) money had and received and (2) fraud.

An action for money had and received "is recognized as an action - an obligation which the law creates in the absence of agreement when one party possesses money that in equity and good conscience he ought not to retain and that belongs to another" Parsa v State of New York, 64 N.Y.2d 143, 148). As to pleading requirements, the essential elements for this cause of action are that "(1) the defendant received money belonging to [the] plaintiff, (2) the defendant benefited from receipt of the money, and (3) under principles of equity and good conscience, the defendant should not be permitted to keep the money." 22A NY Jur 2d, Contracts, § 520, at 244.

The essential elements of a cause of action for fraud are "representation of a material existing fact, falsity, scienter (knowledge of this falsity), deception and injury." Channel Master Corp. v Aluminium Ltd. Sales Corp., 4 NY2d, at 407, supra.

Now, this is what they can attempt to do. Of course, whether or not they are successful depends on whether they can prove the elements of each cause of action. They are unlikely to be able to prove fraud, but they may have a case for money had and received.

Having said that, someone in your situation may have an "affirmative defense" that you reasonably believed that the payments were correct, and as such, had relied on them and spent the money. This borrows on the concept of "estoppel" (RIPPLE'S v. Le Havre Assoc., 88 AD 2d 120 - NY: Appellate Div., 2nd Dept. 1982), i.e. reasonable reliance, although I must say that it is not a strong defense in a case such as this.

If you were to write a letter back using an attorney (this is best, XXXXX XXXXX may understand that you would mire them in litigation and may decide to simply not to pursue this matter) that you plan to fight any such accusation, they may decide to leave you alone.

May I recommend the NY Bar referral program - here. The attorneys are vetted and qualified. You should be able to find an attorney you are confident with and whom you can trust, and who is available ASAP.

Ergo, someone in your situation may wish to write back a letter using an attorney stating all this, and perhaps the entity will back off.

Best of luck.

Please note: I aim to give you genuine information and not necessarily to tell you only what you wish to hear. Please, rate me on the quality of my information and do not punish me for my honesty. I understand that hearing things less than optimal is not easy, and I empathize.

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Customer: replied 1 year ago.


thanks you very much, Ely


 


I did some research on this issue. Some article says, you will always dispute overpayment in error.


1)I did the correct service, they just misunderstanding my medical notes on the records, I explained them already. don't think I have problem


2) You delivered service, you should got pay


3) If the claim period for you service is 3 months, you should also have 3 months time period after you get money from them. if they did not ask you money after you get payment in three months, you don't need pay them back.


 


Could you give me more idea?


 


thanks

Expert:  Ely replied 1 year ago.
Y,

I am sorry for the wait! It looks like there was a glitch on the site...

I did some research on this issue. Some article says, you will always dispute overpayment in error.

I am afraid that this is an over-generalization. Not so.

In short, the law is against you, arguably. If the money does not belong to you under the contract, you should give it back. For example, if I contracted with you that you'd give me 5 apples, and you met me in the evening and accidentally (it was dark) gave me 5 apples, you have the right to demand 1 apple back.

I am sorry.

Gentle Reminder: Again, surely you prefer that I be honest in my answer – please remember that rating negatively due to receiving bad news still hurts the expert – it is simply the way that the system is set up. Please use REPLY button to keep chatting, or RATE my answer when we are finished. (You may always ask follow ups free after rating.)
Ely, Counselor at Law
Category: Legal
Satisfied Customers: 87076
Experience: Private practice with focus on family, criminal, PI, consumer protection, and business consultation.
Ely and 21 other Legal Specialists are ready to help you
Expert:  Ely replied 1 year ago.
Oops, the analogy meant to say:
f I contracted with you that you'd give me 5 apples, and you met me in the evening and accidentally (it was dark) gave me 6 apples, you have the right to demand 1 apple back.

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