By: Michael Branco
The Phia Group’s overpayment specialists received two claims – same provider, same patient – totaling over $760,000. The reason for the refund was that the original repricing was incorrect. Upon contacting the provider, our overpayment case handler was informed that the provider had previously contacted the TPA to provide a refund but an administrative error led the TPA to believe that no refund was due.
This time around, when contacted by The Phia Group, the provider asserted that no refund was due, and even if it was, the TPA’s failure to acknowledge it the first time estopped the TPA from now requesting it. By leveraging the legal framework surrounding the refund request and decompiling the provider’s argument, The Phia Group was able to recover the majority of that overpayment in a settlement that the TPA was more than happy to accept, since the TPA believed that it would not be able to recover a dime.