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It's a bit specialized. I don't know if you can help or not.

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It's a bit specialized...

It's a bit specialized. I don't know if you can help or not. I am a medical services provider and have received an overpayment refund demand letter from an insurance company for which I am not a contracted provider. The overpayment they are claiming resulted from a processing error on their part.

Lawyer's Assistant: What state is this in? And just to clarify, when was the purchase made?

Florida. Don't know what mean by "purchase". The Date of Service was in October or November of 2016. The first demand letter I received was in February of 2017.

Lawyer's Assistant: Has anything been filed or reported?

I have responded on 3 occasions , challenging their demand, and 3 times they have rejected my challenges and restated the demand.

Lawyer's Assistant: Anything else you want the lawyer to know before I connect you?

Just that the repayment demand came after the claim was resubmitted. The company paid for subsequent claims without question. I called them to ask why this particular DOS was denied. The rep I spoke with couldn't tell me and said he would resubmit the claim. It was after review of the resubmitted claim that they paid it, and then later send a refund demand.

Submitted: 8 months ago.Category: Legal
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12/15/2017
Lawyer: INFOLAWYER, Attorney replied 8 months ago
INFOLAWYER
INFOLAWYER, Attorney
Category: Legal
Satisfied Customers: 63,663
Experience: Licensed attorney helping individuals and businesses
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If you contest the demand and have not received a satisfactory explanation the claim need not be paid at this time. Either side can seek to have the issue addressed by the insurance department. The parties can also submit to mediation or arbitration instead of court action. The burden is on the insurer to establish the basis for the demand.You want to prepare your case by creating a time line starting from the earliest event. For each event, write down key details and witnesses and if there is a document that relates to it, save it and refer to it. This timeline can be very valuable in narrating your case and presenting it later in a concrete and specific way.If needed, A lawyer letter from a local lawyer can be effective in several ways. It can avoid costly litigation and help bring about a settlement. It also helps organize the claim and if it goes to court shows the judge you tried in good faith to resolve it!martindale.com and findlaw.com are both excellent lookup directories. Both highly rated. Both used by lawyers. Easy to search and find local options.Please let me know if the reply is acceptable by responding “yes” or “acceptable”
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Customer reply replied 8 months ago
The insurer's reasons have changed with each written exchange we have. The first was that it was a result of a resubmission of the claim. The second reason was regarding questions of "medical necessity". The third time they said the patient's policy had no benefits for the diagnosis. They keep changing the reason with each letter. In the last one I cited references to similar court cases where it was ruled that if the mistaken payments were the result of payor error, and not through any fraudulent activity of the provider, then the provider could not be help responsible and did not have to repay the overpayments. When I submitted this information, the insurer said these court decisions were not in Florida and therefore did not apply to me.
Lawyer: INFOLAWYER, Attorney replied 8 months ago
Their inconsistent reasons will work in your favor and insurer or court would not appreciate the change either.
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Lawyer: INFOLAWYER, Attorney replied 8 months ago
Court decisions from your state would apply and sister states will also be considered especially where law is not inconstant or home state does not have different law.
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Customer reply replied 8 months ago
your suggestion is that I find a local lawyer and not continue to attempt this myself?
Lawyer: INFOLAWYER, Attorney replied 8 months ago
just have the lawyer send a letter at first! They may back down.
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Lawyer: INFOLAWYER, Attorney replied 8 months ago
Good luck!
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Lawyer: INFOLAWYER, Attorney replied 8 months ago
Please do not forget to leave positive feedback by clicking on the 5 stars at the top of your page, as experts are not employees of the site and do not get any credit for spending time with customers unless they leave positive feedback. Thank you.
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Lawyer: INFOLAWYER, Attorney replied 8 months ago
if I can elaborate on anything, just ask me.Awaiting your reply, thank you!
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