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  1. #1

    Unhappy Can Medical Provider Sue Me for Payments Recouped by Insurance from 2004-2008

    My question involves collection proceedings in the State of: North Carolina

    Insurance is recouping payments made to my child's medical provider from 2004 - 2011. Is there a statute of limitations on their ability to sue me for these new "old" debts from say 2004-2008 given the 3-year statute of limitations that applies to most debts in this state.

    Tricare, insurance for the military, has completed some type of internal audit and determined that my child was not eligible for benefits during a period of YEARS even though they gave authorizations, paid claims and continued to show him eligible for services on DEERS. This sudden revelation occurred for them in March 2011. They are reversing and recouping money from every providor my child has seen while under that insurance plan going all the way back to 2004.

    The total monies they are recouping is around $50,000. I have gotten two calls from medical providers. One provider, a therapist office, is stating that Tricare is demanding a refund of $20,000.

    Of interest, these providers have 30 days to reimburse the money to Tricare or Tricare will begin offsetting their claims. Meaning, if they have other clients with that same insurance, they will keep the money they would have otherwise paid for those patients and apply it to the debt they owe for my child's claims.

    It's important to note that the insurance company has not contacted me about this at all. I had to contact them and ask them what was going on. They said I am not responsible for repaying the funds, the medical provider is. Yeah, but they must know that the medical provider is going to come after me for the payment. Tricare has compiled all of the claims they have decided to recoup on FINALLY sent me a list of all the providers they have contacted so I'm not completely caught off guard when the bills come. Already I have had two very unpleasant conversations with two different office managers. I feel like a sitting duck. Everytime my phone rings I cringe.

    My child saw so many providers during this time period because that was the time period when he was being diagnosed with autism and was receiving all kinds of tests like sleep deprived EEG's. He saw psychologists, neurologists, speech therapists, occupational therapists, etc. etc. etc. and even had two surgeries on his back for a tumor he had developed. All these years later they want ALL of their money back from these procedures.

    My question is, if a provider who was initially paid on time by the insurance company, has to reimburse my insurance company for services received from 2004-2008 etc. would their lawsuit likely be successful given the statute of limitations (I believe it is 3 years in this state for debts and unjust enrichment in NC).

    This is a portion of Tricare's SOP handbook.

    http://www.tricare.mil/to02/C11S3.PDF

    Additionally, my insurance had a contract with Tricare so that the provider could not bill me anything above what Tricare paid. Now that Tricare is saying my child was not eligible, the medical provider is stating there was no contract and therefore I should have to pay a 100% of whatever they billed Tricare. So that if they billed 100.00 for one appointment and Tricare paid only 60.00...and then recouped 60.00...they would then send me a bill for 60.00 plus the 40.00 that was discounted pursuant to their contract with Tricare. Can they do that per the statute of limitations?

    Thank you.

    I guess I should have posted this under Debt Collections > Medical Debts (I just now saw that...sorry)

  2. #2
    Join Date
    Jan 2006
    Posts
    38,867

    Default Re: Can Medical Provider Sue Me for Payments Recouped by Insurance from 2004-2008

    why was the child ruled ineligible for coverage?


    Given the amount of money involved, I would seriously suggest hiring a lawyer to help you with this. Depending on why the child was ruled ineligible, you may or may not have a defense against the medical providers. The ruling of eligibility could be in error as well.

  3. #3

    Default Re: Can Medical Provider Sue Me for Payments Recouped by Insurance from 2004-2008

    Tricare recouped the money because they said the sponsor was not on active duty status during the times that the claims were paid. It really is not worth it to rehash that part of it because the fact is that regardless, I am going to get nowhere with Tricare. I want to know if the providers can come after me for service dates before 2008 (considering the three year statute of limitations).

  4. #4
    Join Date
    Jan 2006
    Posts
    38,867

    Default Re: Can Medical Provider Sue Me for Payments Recouped by Insurance from 2004-2008

    I want to know if the providers can come after me for service dates before 2008 (considering the three year statute of limitations).
    Part of it will depend on whether you should have known the child should not be covered. If it can be considered to be fraudulent on your part, then the 3 year SOL for a debt is not the SOL you need to be concerned with. I'm not saying your actions were fraudulent. I am saying there is enough involved here that it might be possible for a claim of fraud to be considered. I just don't know enough about Tricare to say is this is something you should have known or not. Your claim of the system that verified eligibility showed him to be covered does not excuse a person being held to a point if they should have known the system was incorrect and no further actions to verify the statements was made.

    There are possible claims they can make and possible defenses you can put forth regarding this issue out sided of the statute of limitations. The problem with any of it is: none of it means much unless/ until you are sued and you can put forth those defenses in court.

    There is just too much not known to give a solid answer to your question.

    If I were you, I would start with arguing the SOL expiration and see if they simply drop the issue. If they don't, then you will be forced to deal with it, including in court should they choose to sue you.

    Unless you knew the child should not be covered, I believe your argument is with Tricare. It is they who approved the services as being eligible. Their actions are why you are where you are now. I surely would not give that possibility up, unless of course, you knew the child should not have been covered at the time. Then, the providers have a win because you would have allowed the billing and payment through Tricare knowing it was incorrect.

  5. #5

    Default Re: Can Medical Provider Sue Me for Payments Recouped by Insurance from 2004-2008

    Quote Quoting jk
    View Post
    Part of it will depend on whether you should have known the child should not be covered. If it can be considered to be fraudulent on your part, then the 3 year SOL for a debt is not the SOL you need to be concerned with. I'm not saying your actions were fraudulent. I am saying there is enough involved here that it might be possible for a claim of fraud to be considered. I just don't know enough about Tricare to say is this is something you should have known or not. Your claim of the system that verified eligibility showed him to be covered does not excuse a person being held to a point if they should have known the system was incorrect and no further actions to verify the statements was made.

    There are possible claims they can make and possible defenses you can put forth regarding this issue out sided of the statute of limitations. The problem with any of it is: none of it means much unless/ until you are sued and you can put forth those defenses in court.

    There is just too much not known to give a solid answer to your question.

    If I were you, I would start with arguing the SOL expiration and see if they simply drop the issue. If they don't, then you will be forced to deal with it, including in court should they choose to sue you.

    Unless you knew the child should not be covered, I believe your argument is with Tricare. It is they who approved the services as being eligible. Their actions are why you are where you are now. I surely would not give that possibility up, unless of course, you knew the child should not have been covered at the time. Then, the providers have a win because you would have allowed the billing and payment through Tricare knowing it was incorrect.
    I've been arguing with Tricare since March. I've gotten nowhere. They will barely talk to me about it because they say they aren't recouping from me. I did not know my child was ineligible and I relied on the information provided by DEERS. There was no fraud involved. Tricare also did not deem it to be fraudulent, I explained everything that I knew to them and they do not start the re-coupment process until allegations of fraud, if any, have already been dealt with. I guess I just have to wait and see what the provider will do.

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