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Insurer pays claim then wants cash back

It’s been more than three years since Lisa Dowden had gastric bypass surgery. As the operation has receded into her medical history, however, her insurer has renewed its interest.

In September, Dowden, a 51-year-old partner at a law firm in Washington, received a letter informing her that her health plan had overpaid by more than $9,000 what it owed for the services of the assistant surgeon in her operation.

Dowden, the letter said, is responsible for paying it back.

Dowden disagrees. Because she used an out-of-network doctor for the procedure, the insurer sent payments for the providers directly to her, a not-uncommon practice when an insurer doesn’t have a contractual relationship with a doctor.

Dowden says she never cashed the checks she received for the surgery and other services related to her procedure.

She simply signed the checks over to the doctor’s office, and it handled the insurance billing.

“I do not see any way that any amount of diligence on my part could have prevented the mistake, if indeed there was one,” Dowden says.

Dowden is preparing to appeal the health plan’s decision. Among many unanswered questions, she’s uncertain why the insurer is pursuing her rather than the provider. She has requested but not yet received information from the staff at the physician’s office.

CareFirst BlueCross BlueShield, which insures Dowden and her husband through a plan for federal employees, said in a statement that it’s obligated under its contract with the federal Office of Personnel Management to attempt to recover any overpayments it identifies that were made to providers or patients.

It added, “we are obligated to recover the overpayment from the member, even if s/he paid the entire check to a non-participating provider, because the overpayment was made to the member” and the member is ultimately responsible for the provider charges.

Such an arrangement is not unusual in cases involving out-of-network providers, says Susan Pisano, a spokeswoman for America’s Health Insurance Plans, a trade group.

“Typically, the transaction would be between the health plan and the patient, when you’re talking about a nonparticipating physician,” she says.

Experts say that overpayments can occur for various reasons. An insurer may simply make a mistake and pay a provider more than the contracted amount for a service, for example.

Or a provider may be paid for a service that’s not covered under the patient’s insurance plan.

“This is a big problem,” says Mila Kofman, a research professor at Georgetown University’s Health Policy Institute and Maine’s former superintendent of insurance. “It shifts responsibility onto patients and providers, who are in the worst position to address problems like this.”