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My Insurer Says It Paid Too Much. Do I Have To Reimburse Them?

Michelle Andrews answers a reader question about having to repay an insurer that says it reimbursed too much after the patient received care from an out-of-network provider.

QUESTION: I recently received a bill from my insurer related to a pre-approved operation three years earlier with an out-of-network provider. The insurer says it mistakenly reimbursed me too much and I owe $9,100. Can they do this? – Lisa.

ANDREWS: They may be able to ask you to repay that money. These situations can come up for different reasons, but often you’ll see it in instances when someone receives care from an out-of-network providers, as you did. The insurer may send the check – or checks – directly to you, the health plan member, leaving it to you to pay the provider who delivered the care. According to insurance industry experts I spoke with, from the insurer’s perspective, that approach is sensible since they don’t have a contractual relationship with the out-of-network provider. Unfortunately that may mean that you – the health plan member – are responsible for repaying any amounts that the insurer sent you and later determines that it overpaid, even if you sent that money directly to the provider, perhaps without even cashing the check. If you want that money back to repay the insurer, you may have to go looking for it from the provider.

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