Robert E. Goff, who recently retired as CEO of University Physicians Network, discusses strategies for confronting payer claw-backs in healthcare payments. He emphasizes the importance of responding promptly and disputing any demand for refunds, highlighting legal rights and proper documentation needed to protect against unauthorized recovery efforts. Goff warns that failing to act can lead to increased financial losses for physicians due to excessive refund demands.

1. W
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2. Robert E. Goff
Formerly CEO at University Physicians Network, LLC (UPN)
Recently retired following 18 years as the CEO of University Physicians, capping a 45 year career in the healthcare industry. He
has seen the great transformation of healthcare delivery into the industry that it is today from the vantage points as a hospital
administrator, regulator, managed care executive, and association executive. He is a founding director of RIP Medical Debt, a
charity that acquires and abolishes consumer medical debt.

3. OFFICIAL DISCLAIMER
The information presented is for general information only and are not meant to substitute for
legal advice. Always seek the advice of an attorney on legal matters.
The presenter makes no recommendation as to an individual physician’s participation or non-
participation with any specific health plans, insurance company or payer. Each physician is
urged to give due and proper consideration to their own individual practice needs and act
independently regardless of the actions or non-action of other physicians.
Legal Guidance
Misuse of the handouts, copy righted © material is subject to fine of $5000 per occurrence
01

4. 02
HOW TO CONFRONT PAYER-CLAW-BACKS
• Just because you have been paid does
not mean you get to keep the money
• Payers regularly seek recovery of
payments through “post-payment” audits.
• Often payers will employ outside commission based audit firms to mine paid
claims data, identify alleged overpayments, and seek recovery – from you.
• You have the right to protect yourself and your income from these efforts
• Act promptly to confront these challenges.

5. 04
SILENT MEANS CONSENT
IF YOU DO NOTHING – THE PAYER WILL “EXTRACT” THE FUNDS
FROM A FUTURE PAYMENTS TO YOU
When you receive a letter asking for the return of an
allege overpayment you must respond timely Demand your rights - DISPUTE
• Federal Fair Debt Collection Practices Act
– You have the right to be presented with
evidence that you in fact owe the money
– The creditor has no right to harass you
• US Postal Code
• Disputing will
– Protect your rights
– Delay any recovery payment
– Give you the information you need to
consider their demand without doing
research through your records (Maybe
they are right)
– Increase their costs of doing business
NYS requires that plans
provide at least 30 days prior
notice
Common “reasons” for
recovery requests
•Another payer was primary
•Overpayment in error
•Duplicate payment
•Patient not eligible at time of
service

6. 05
RESPOND IN WRITING - ONLY
• If you receive a telephone call
from the payer or their agent:
refuse the call.
– Train your staff to tell any
callers to put the request
in writing and mail it to
your office.
– Do not offer your fax or
email information
• If you receive a fax requesting
a refund:
– Write REFUSED on the fax,
date it, and send it back
– Add: use of this fax for PHI
may constitute a violation
of HIPAA and is reportable.

7. 06
LETTERS DEMANDING REFUNDS ARE OFTEN CRYPTIC
THE REGULATIONS REQUIRE: “SUCH NOTICE SHALL STATE THE PATIENT NAME, SERVICE
DATE, PAYMENT AMOUNT, PROPOSED ADJUSTMENT, AND A REASONABLY SPECIFIC
EXPLANATION OF THE PROPOSED ADJUSTMENT”
Your letter must state: You dispute their allegation and request:
Proof that they are in fact entitled to a refund.
1. A detained explanation of the basis for their demand
2. A copy of the agreement that they are authorized to represent the payer
3. A copy of the original EOB
4. A copy of their proof that the patient was enrolled in another plan and that plan was primary (if claim is
another payer responsible)
1. An explanation of why it is your responsibility to purse the patient, as the patient not disclosing
the other insurance amounts to fraud. And proof that they have filled fraud charges against the
patient, as they are the party making the accusation
5. A copy of the fee-schedule, certified as effective as of the date of service (if they claim overpayment)
6. A detailed explanation of how they arrived at the amount they allege to have been paid in error
7. A copy of the cancelled check in proof that you actually received payment
8. An explanation as to why state prompt payment regulations are not applicable (Those regulations allow
the payer 30 days to investigate a claim prior to payment)
9. An explanation as to the time lag between he discover of the “error” and the demand to you.
10. Any other “documentation” that you believe is necessary to prove that they are owed the money

8. 07
ASSERT THE FOLLOWING IN YOUR RESPONSE
1. State that you reserve the right to request that their response be
reviewed by the State Health Commissioner (or Attorney General) the
Department that licenses the health plan in your state prior to acting
on your demand.
2. Their request is disputed in accordance with your rights under The
Federal Collection Practice Act.
3. Remind them that under The Act they can take no action prior to the
provision of proof of the legitimacy of their claim
4. Remind them that State regulation specifically precludes their
unilateral off-set of their alleged overpayment.
5. That your office will only consider written a response to your request,
including all requested documentation, and no telephone, email or fax
communication should occur.

9. 08
YOUR RESPONSE IS A DISPUTE – NOT APPEAL
• Some plans and their agents like to send form letters in response that
your appeal is denied.
• Tack on to a copy of your letter the following and send as a response:
• “Our response to your demand for a refund is a DISPUTE, not an
appeal. A dispute is our right under the Federal Fair Debt Collections
Practices Act, and must be treated in accordance with the provisions of
that law. Your intentional falsification of our response as an appeal is a
blatant attempt to deprive us of rights under the law and is now
documented. If an appropriate response is not received by this office
within the next 15 days, or if any action is taken to our disadvantage, a
complaint will be filed with regulatory authorities” (If the demand is
from a third party on behalf of a payer add: “as well as the integrity
office of xxx Health plan”.

10. 09
REMEMBER – PAYERS WILL SEEK TO CLAW BACK FUNDS,
EVEN IF THEY ARE NOT LEGALLY ENTITLED
TO THEM
“Just because NYS regulations say we can’t off-set the money, that does not mean we can’t ask for it
back, physicians are expected to know their contract and the regulations”
Loran Firbush, Oxford Health Plans (A United Healthcare company)
NYS Regulations
•Retroactive terminations – While these should always be disputed, NYS limits the exposure to 120
days from DOS. No longer can they go back years to seek recovery of claims paid. (If services
received prior authorization)
•Authorizations can’t be withdrawn, if required for a service, and given, unless the patient is not
covered, or false information was relied upon in granting the authorization initially.
•Look back at paid claims is limited to 2 years from payment, unless suspicion of fraud or abuse
•Negative remits/off-sets; require at least 30 days prior notice. Time for the physician to dispute,
but you must read and act on your mail.

11. 10
WHAT WILL HAPPEN
• In many cases the agent/plan will abandon their demand from you, and
you will hear nothing further.
• If you do get a response, you may find that in fact you were over paid –
the right thing is to refund the money.
– If the claim is that another payer is primary – bill that payer, if they pay, you refund
the payment, if they do not, for whatever reason, their denial makes the plan that
paid you primary, and no refund is due.
• Your dispute will delay any potential refund, potently eliminate it, and
in any case, increase the plan’s operating costs.
• Physician offices that push back experience less refund demands than
those that readily send money

12. 10
IN SUMMARY
• What is you do discover you
have been overpaid?
• Don’t send the money back
• Cash the check
• Keep the money aside
• Send the money back only when
they ask for it
• Note: Don’t do this for Medicare –you
have 60 days to return identified
overpayments, and failure to is subject
to the penalties of the False Claims Act
• Claw-backs reduce physician income by 2%
or more
• If you do nothing – you will lose, and if you
get a reputation for refunding or allowing
claw-backs, more will likely occur
• Your response
• Dispute – promptly and forcefully