Overpayment Recoveries: Takebacks Provider Support Services

What is a Takeback? A takeback occurs when an overpayment is identified. As an alternative to sending an overpayment letter, SummaCare deducts the overpaid amount from payment on future claims.

Benefits of Takebacks Eliminates Paperwork in your office Overpayment letters will not be sent EOPs are generated when a takeback is initiated Currently, we are unable to generate an EOP when we receive a refund Easily Trackable Negative Balance report carries data from EOP to EOP More Efficient No longer necessary to send a refund

Identifying an Overpayment The following slides review how overpayments are discovered and the process that takes place to correct the overpayment.

SummaCare Identifies Overpayment SummaCare will reprocess the claim that has been identified as overpaid The overpaid claim will reprocess through our payable cycle to ‘takeback’ the payment A negative provider balance is initiated The 835 (electronic Explanation Of Payment) or paper EOP sent to the provider will include line item details of the takeback and the negative balance amount. Negative Balance: When an overpaid claim is discovered and SummaCare adjusts the claim resulting in a negative provider balance.

Provider(s) Identifies Overpayment – Returns Check Provider returns the SUMMACARE check to SummaCare SummaCare voids the check A negative provider balance is not initiated as the payment was an exact reversal

Provider Identifies Overpayment – Sends Refund The provider’s refund check is logged in the Overpayment Department. The claim is adjusted in order to post the refund An EOP cannot be generated to show the refund has been posted. A negative provider balance is not initiated

Take Back Process The overpaid claim will be reprocessed A negative provider balance is the result of the overpaid claim A takeback is initiated to deduct the overpaid amount from future claim payments, IF the provider submits other claims that meet the following conditions : Claims are submitted under same provider number as the overpaid claim Claim is submitted for the same type of plan as the overpaid claim Claim submitted is for the same member group number as the overpaid claim Claim does not have to be for the same member A negative provider balance may or may not be fully recovered on the same EOP as the original overpaid claim If the negative provider balance is not fully recovered on the same EOP, the outstanding negative balance will be listed on the last page of the EOP.

Take Back, Cont’d. Future payments to the provider will be reduced until the Negative Balance has been eliminated Previously identified conditions must be met. SummaCare will monitor the unapplied negative provider balance If the negative balance exists after 60 days, a refund letter will be sent to the provider If the refund is not received within 30 days of the refund letter being sent, the negative provider balance will be forwarded to a collection vendor.

Take Back, Cont’d. If the provider refunds the full negative balance before the take back process resolves the negative balance, SummaCare will adjust the claim to systematically resolve the negative balance and apply the refund check. If the refund payment is received after the negative balance has been resolved, the refund check will be applied to the provider’s outstanding balance, if applicable If there is no outstanding balance, the refund check will be returned to the provider.

Please Note: Take Backs can only be performed if the claim that is submitted are for services for a member that belongs to a current/active group If the group no longer has SummaCare coverage, a takeback cannot take place. The provider must be currently contracted with SummaCare If the provider’s contract with SummaCare is terminated and a negative balance exists, the provider will need to refund the outstanding negative balance amount.

Questions? Please contact Provider Support Services email contactproviderservices@summacare.com Call 800-996-8401 or 330-996-8400