If I’m a physician who sees patients in a hospital and bills for my services to the insurance company, what are my rights in the case of a retroactive disenrollment?

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If I’m a physician who sees patients in a hospital and bills for my services to the insurance company, what are my rights in the case of a retroactive disenrollment?

I took care of a patient about 10 months ago for several days. The insurance paid me for those services. Now I have received a letter saying that due to “retroactive disenrollment” I have to refund the amount that was paid to me. Is that legal?The patient passed away a few months ago. Who is supposed to pay for my services?

Asked on January 19, 2014 under Business Law, Tennessee

Answers:

MD, Member, California Bar / FreeAdvice Contributing Attorney

Answered 7 years ago | Contributor

The insurance already paid you and that is not your problem. This is the insurance company's problem. You don't need to sue the patient's estate. What you need to do, however, is place everything in writing indicating you were paid for services at the time of those services and it is not your problem or responsibility to ensure the insurance would not be "retroactively disenrolled." Your payment did not include any conditions and you are not refunding any monies owed. The cashing of your check operates as an accord and satisfaction of any issues the insurance company may have had at any point. Then, file a consumer complaint with your state's insurance department regarding this possible consumer protection act violation and bad faith insurance practice.


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