Watch Your Upper Payment Limits Or You Could Be Responsible For Refunds

When receiving medical payments after billing, it is important to make sure the upper payment limit is accurate. If the upper payment limit is too high, you may end up having to refund Medicaid or Medicare. North Carolina is currently going through this medical billing upper payment limit problem.

In North Carolina, the Office of Inspector General did an audit and found that in 2003, the state was miscalculating inpatient payments. Apparently, when doing medical billing, they began figuring the upper payment limit by taking Medicaid charges changed to costs. They were supposed to figure the medical billing limit by using the hospital’s recent cost reports. The result was a $42 million miscalculation and overpayment. This money will have to be refunded.

When billing for a certain procedure it is best to estimate what you think the medical reimbursement amount will be. If the amount you get in return is significantly less or significantly more, be sure to ask questions to figure out why that has happened. It may seem like a great thing to get medically reimbursed more money then you billed for, but as North Carolina is finding out, it will come back to haunt you.

Each hospital in North Carolina will have to pay back every last penny Medicaid overpaid. It doesn’t matter if it is already spent, they have to be refunded. It is not an easy thing paying back millions of dollars.

Outsourcing your medical billing can prevent errors like this from happening. They are aware how much money should be reimbursed from each insurance company and from Medicaid. These medical billing firms deal with payers every single day. When it comes to inflated upper payment limits it is always best to leave problems up to the medical billing professionals.

View all Articles by: Melissa Clark, CCS-P