HNS Policy

Payments to Which the Provider is Not Entitled

 

HNS Policy:

  1. Contracted health care professionals shall not retain fees received for services provided to which they are not entitled.

  2. If a contracted health care professional becomes aware of a payment to which he/she is not entitled, the contracted health care professional shall take all actions necessary to ensure the timely return of those funds, to the applicable party, and shall do so in accordance with any directive issued by HNS, or the contracted payor.

  3. If a contracted health care professional receives an "overpayment" (i.e. - payment in excess of the contracted allowable; payment for services not provided, payment for services which a payor determined were not medically necessary, or which were not provided consistent with payor corporate medical policies and/or which HNS determines were not consistent with HNS Policies, and/or, or to which he/she is otherwise not entitled) the contracted health care professional shall timely repay those monies to HNS, or as applicable, to the contracted payor who paid the funds, and shall do so pursuant to any directive issued by HNS or a payor.  This policy survives the termination of the HNS Practitioner's Participation Agreement.

  4. If a contracted health care professional receives a payment, or payments, for services to which he/she is not entitled, he/she should contact his/her HNS Service Rep to make HNS aware of the issue. However, IF the amount of the sum of the payment(s) are equal to or exceed $250.00, the contracted health care professional must promptly notify HNS of the overpayment(s).

  5. HNS, at its sole discretion, may require the contracted health care professional to submit a certified check or money order, payable to HNS, to the contracted payor, or to a member, for the full amount of the overpayment. If repayment is required by HNS, providers shall promptly comply with such requests, and shall repay the entire amount of the overpayment in the manner and form specified by HNS.

 

 

Provider Errors (Inadvertent Errors)

 

HNS Policy:
If a contracted health care professional receives a payment for a service to which he/she is not entitled, due to an inadvertent error by the contracted health care professional, and when the filing of a "corrected claim" by the contracted health care professional is the appropriate course of action to resolve the issue, the contracted health care professional shall file a "corrected claim" and shall do so within 15 days for the date he/sh becomes aware of the overpayment.

 

 

Payer Recoupments

 

As a general rule, when a payor discovers it has made a payment to provider to which he/she was not entitled, the payor will recoup those monies from future payments owed to the provider.

 

HNS Policy:
If HNS receives notice from a payor that a refund is due, or otherwise determines the provider has received monies to which he/she is not entitled, as a general rule, HNS shall recoup those monies from subsequent payments otherwise due to the provider who received the overpayment. However, HNS, at its sole discretion, reserves the right to require the provider to issue a certified check or money order, to HNS, or to the payor, for the full amount of the overpayment, and providers shall promptly comply with any such request.

 

Contracted health care professionals shall allow HNS, and, as applicable, contracted payors, to recoup the total amount of any overpayments, from future HNS payments, until the amount due has been repaid.

 

If the individual provider to whom the payment was issued is an employee of another HNS provider, providers shall allow HNS to recoup the funds from the employer physician under whose EIN the payment was reported.

 

HNS, in order to recoup the entire amount of the overpayment from the provider, may recoup up to the total amount of the overpayment, from any and all payments HNS has received, from any payor, which are otherwise owed to the provider.

 

HNS, in order to recoup the entire amount of the overpayment from the provider, may recoup up to the total amount of the recoupment, from any and all future payments HNS receives, from any payor, which would otherwise be owed to the provider.

 

 

Recovery of Payments after Termination 

 

Providers shall remain liable for overpayments that occur as a result of services provided prior to termination. Should a payor recoup monies from HNS, or request the repayment of monies by HNS, associated with services provided by a contracted health care professional who is no longer an HNS participating provider, HNS reserves the right to pursue all remedies available at law it believes necessary or appropriate, in connection with collecting those funds from the provider.

 

 

Refunds to Patients

 

HNS Policy:
If HNS or a payor determines a provider has received payments from a patient to which he/she is not entitled, and determined those fees must be refunded to the patient, contracted health care providers must refund those monies to the patient within 10 days of the date HNS notifies the provider that a refund must be issued.

 

HNS may require the contracted health care professional to provide HNS with a copy of the check issued to the patient, and if so, the provider shall comply with that request.

 

 

Refunds to HNS

 

HNS Policy:
Unless specifically instructed to do so by HNS, contracted health care professionals shall NOT issue refund checks, either directly to HNS, or to an HNS contracted payor.

 

Providers shall resolve repayment of funds to which they are not entitled pursuant to these policies, and/or to specific directives issued by HNS.

 

 

Underpayments

 

If a claim (or claims) was adjudicated incorrectly by the payor, and the EOB/NOP reflects less than the contracted allowable, please contact your HNS Service Representative for assistance in resolving the issue.