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September 20, 2011

Dear Colleagues:

This message is relayed from the CMA and is a benefit of belonging to ACP.

Blue Cross seeking to settle overpayment refund requests; physicians encouraged to carefully review settlement language before signing As previously reported, the California Medical Association (CMA) has received a number of complaints from physicians that the Anthem Blue Cross Special Investigations Unit (SIU) is requesting refunds outside of the 365-day period allowed by California law.

State law allows health plans to pursue recovery of any type of overpayment made to providers within 365 days of the date the claim was paid. For claims older than 365 days, plans can seek to recover overpayments only if the alleged overpayment was "caused in whole or in part by fraud or misrepresentation on the part of the provider." CMA believes that Blue Cross is using an overly broad definition of "misrepresentation" to seek recoupment on claims older than one year.

In June, CMA filed a formal complaint with the Department of Managed Health Care (DMHC) asking that it investigate these potential violations. DMHC subsequently referred CMA's complaint to its Enforcement Division.

Within the past week, CMA has received calls from physicians who report that they have been contacted by Blue Cross SIU, offering to reduce overpayment amounts due if they agree to sign settlement agreements. CMA believes some of the recoupment requests that the SIU is trying to settle may be the same requests that are the subject of our complaint filed with DMHC.

Physicians who are approached to sign any type of settlement agreement are strongly encouraged to ask for the offer in writing and to have an attorney review the settlement before signing. Often, these types of settlement agreements require that physicians waive and abandon their legal rights over the moneys at issue.

To help physicians understand their rights and options when it comes to health plan refund requests, CMA has published a "Special Investigations Unit Audit Guide." This document is available free to members in CMA's online resource library.

Contact: CMA's reimbursement helpline, (888) 401-5911 or economicservices@cmanet.org.


Page updated: 09-20-11

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