Doctors tussle with insurers — and sometimes patients lose, too

July 18--Dr. Robina Poonawala riffles through a stack of letters from insurance companies that all sound the same: We've discovered we overpaid you for taking care of a patient. You have 30 days to pay us back -- or we'll deduct the amount from your next check.

Sometimes, the amount in question is less than $5; occasionally, it's over $100. Most are in between. Some refer to care provided more than a year ago. All of it is a paperwork pain for Poonawala, a solo family medicine practitioner in Austin who has begun to fight back but doesn't expect to win.

"You feel like you're being slapped on both cheeks," she said.

Most patients aren't aware of this behind-the-scenes tussle, but they might feel the effects -- beyond encountering a frustrated doctor distracted by billing queries.

Some patients might discover their doctors no longer accept coverage from their insurance carrier, and more doctors have stopped taking insurance altogether -- roughly 10 percent in Texas, according to Texas Medical Association surveys. Their patients could lose access to those doctors. Some will pay more to keep seeing a favorite physician by going "out-of-network." And others might face higher costs as physician overhead climbs, experts said.

In most cases, doctors can't legally ask patients to share the cost.

Virtually all of the insurance companies and government-sponsored coverage programs in Texas and other states engage in the longstanding practice called "recoupment." Doctors, lawyers and others said commercial insurers' attempts to recoup overpayments have been escalating over the past five years. Some see a money grab by an industry that might have declining profits, partly because the Affordable Care Act requires insurers to spend 80 percent of premium dollars on patient care.

Doctors have contracts with insurers that detail what is covered and how much reimbursement is owed. But sometimes after the insurance company pays the doctor, it goes back and reviews the claim. The demands for recoupment can come months later, long after the doctor's office has closed the transaction. The doctors can dig back through the records to appeal, but many don't consider it worth the staff time. For Poonawala, the nickel-and-diming added up to real dollars, and many refund demands came more than a year later, she said.

"It's just greed," she said.

"Absolutely not," said Clare Krusing, a spokeswoman for America's Health Insurance Plans, which represents health insurers. "The goal is to provide consumers with affordable coverage. When there are errors, we need to address those."

Some of the errors stem from physicians using the wrong billing code, she said. When doctors use paper, rather than electronic claims, error rates rise, Krusing said.

"Overpayments shouldn't happen in the first place," she added. "There needs to be a system where the accuracy of payments is a streamlined process."

Recoupment -- which can occur for many reasons, including billing a higher amount or billing the wrong carrier when a patient has additional coverage -- is among the top five complaints the Texas Medical Association receives from its doctor members, regardless of practice area, said Genevieve Davis, the TMA's director of payment advocacy.

The TMA has helped some doctors with payback demands, and it's not unusual for the insurers to back off, Davis said.

"I would say I hear from hundreds of physicians a year about this, if not thousands," she said. "I think it's one of those things patients don't realize is even going on."

Unless they lose their doctor.

Recoupment is one reason Dr. Todd Crump, a primary care physician in Austin, said he no longer takes insurance.

He practiced with a group in Taylor several years ago when an insurance company audit found overpayments, many involving technicalities, he said.

"They said, 'there's a checklist you didn't document,'" Crump said. "A lot of it is just nonsense, in my opinion."

As a no-insurance provider, building a patient base takes time, he said. "It's a trade-off. You get paid more if you take insurance, but the flip side is you have to follow all their rules and play their game."

Many doctors simply pony up when hit with a payback demand.

In the last six months, Poonawala said Humana -- which has sent her the highest number of recoupment demands -- has cited scores of overpayments, primarily for lab work, totaling $5,400. Poonawala hasn't paid, and Humana hasn't reimbursed her services for several months. It's still deducting what it says she owes, said her husband, Nadir Poonawala, an accountant who helps with the books.

"If it's too high, then pay less. ... We've already done the service," he said. "It's Humana's mistake."

Humana, which Aetna is seeking to acquire, declined to comment. "In June, Humana announced it is observing a 'quiet period' on media inquiries until July 29," spokesman Ross McLerran said.

Dr. Poonawala has changed how she bills for laboratory services, Nadir Poonawala said, but the couple and their lawyer daughter, Omaima Poonawala, believe Humana owes the doctor for services she provided.

Robina Poonawala hired an employee, Shazia Baloch, to help sort through the insurance company demands. Baloch said she spends two or three hours a day calling insurers. While doctors have 30 days to issue a refund, insurers don't have any such deadlines on recoupments, she said, citing a recent demand letter over care provided in 2008.

If the doctor doesn't pay up in a month, penalties and interest start, documents show.

Calling the company to ask questions is generally an exercise in futility, the Poonawalas said. At one point, Robina Poonawala sat down with Humana's medical director but nothing changed, Nadir said.

Dr. Poonawala doesn't want to drop Humana or stop taking insurance. "It's not fair to excommunicate patients," she said.

Just a year ago, Humana sent her a letter saying she had earned a bonus based on claims information submitted on behalf of Humana's Medicare Advantage patients. In 2012, Humana also congratulated her for receiving a 93.75 percent compliance score after a medical records review.

Jamie Dudensing, CEO of the Texas Association of Health Plans, said insurers are being squeezed, too. "It is a difficult task to keep health care costs affordable and competitive in the market right now," she said. "The insurance companies are looking to make sure everything is appropriate."

Doctors who study their health plan contracts can sometimes avoid being surprised by overpayment demands, experts said.

"Our contracts with the care providers participating in our network specify the rates that should be charged for various services, and if a payment exceeds the contracted rates we may follow up with the care provider to ensure the appropriate balance is collected," UnitedHealthcare spokeswoman Mary McElrath-Jones wrote in an email.

Tamara Rodriguez, a lawyer with Vidaurri, Lyde, Rodriguez and Haynes in Edinburg, said it pays for doctors to fight back. Some doctors are hiring lawyers, especially when the stakes are high, she said.

One reason the recoupment practice is escalating is that insurance companies have seen the government's Medicare and Medicaid programs collect substantial paybacks after fraud investigations, Rodriguez said. They want to try and get money back, too, she said.

Even so, she said, in at least half of the cases she knows about, commercial insurers miscalculated. She cited two cases in which doctors protested recoupments exceeding $10,000: one was refunded 65 percent and the other got 85 percent.

"They're banking on you not responding," Rodriguez said. "A lot of times it's nitpicky things, and they (doctors) just need to do a corrected claim."

Bradley Reiner, a practice management consultant whose clients include the Texas Academy of Family Physicians, said, "Payers are trying to collect as much money as possible, and this is an easy way to do that. Doctors don't have much recourse."

Dr. Poonawala said that's how she feels: "It's not fair to doctors, and it's not fair for patients."

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