You can be billed in NC years after your insurer paid a claim. Here’s why.

The United States’ fragmented and dense healthcare landscape often leads to players within it passing around the hot potato.

In this case, the hot potato is the bill.

Insurers say they need to scrutinize claims to make sure there’s no fraud and that they’re only paying what’s due, especially as the prices and bills passed along to them by doctors and other providers continue to rise, driving up the premiums insurers charge. Recently, that scrutiny has come to include using artificial intelligence to make coverage determinations.

Meanwhile, providers say insurers create dense billing and reimbursement rules to justify denying or reducing payment.

“It’s a pox on both your houses,” said Amy Killelea, an assistant research professor at Georgetown University’s Center on Health Insurance Reforms in Washington, D.C. “There’s just a lot of unnecessary complexity and opacity in the system that leaves a lot of room for error and for fighting between providers and payers, and that’s where the consumer gets left — in the middle of that big fight.”

Claims can be denied by insurers before payment — or even retroactively, after they’ve already been paid.

Insurance companies can reverse their decisions and refuse to pay claims weeks, months or even years after the fact, The News & Observer found in interviews and public records.

In North Carolina, a claim payment can be clawed back — via a demand for a refund or by offsetting future payments — from healthcare providers or facilities up to two years after it was paid. After that two-year window closes, the insurer can no longer claw back the money unless it has a “reasonable belief” that fraud or intentional misconduct occurred, or that the provider was paid for the same service by both a private insurer and a government payer, such as Medicare, says state law.

Providers also have a two-year period after claim adjudication to request that insurers pay for any underpayments or nonpayments.

The N&O reached out to the North Carolina Association of Health Plans, which represents various commercial insurers, by telephone last week to get comment on the use of retroactive claim denials and adjustments. Its executive director, Peter Daniels, said he was going to be away and could not respond. The N&O followed up Tuesday via email but did not receive a response.

There are several “flavors” of insurance denials and “retroactive claims denial is one specific category of a broad array of the different ways claims are denied,” said Killelea. “What’s obviously concerning about the retroactive denials is that they are often a shock.”

The two-year look-back period isn’t standard nationwide. According to Killelea, some other states have shorter, tighter look-back periods — Maryland, for instance, has a six-month look-back period.

Becky Greenfield, a partner at Wolfe Pincavage, a Florida law firm that represents healthcare providers nationwide in disputes, said providers and insurers also negotiate their own look-back rules in contracts. Beyond that, cases can also be brought to court.

The N&O requested complaints involving retroactive recoupment received from 2025 through mid-April 2026 by the Consumer Services Division of the North Carolina Department of Insurance, which regulates insurance plans.

The N&O received 28 files, which included complaints largely filed by providers. Several of these cases involved allegations that insurers had reprocessed a claim and then erroneously taken back payments from providers. Others involved insurers taking money from one provider to cover a debt owed by a different provider — one that had treated a different family member covered under the same insurance policy.

Still others involved retroactive coverage cancellations, sometimes because employees were accused of not paying premiums or because employers were said to have backdated the effective dates of coverage.

In some cases, involvement by the Department of Insurance led insurers to reverse the recoupment and return providers’ money. But in several others, state involvement did not change the outcome.

That occurred, for example, when the dispute fell outside the department’s jurisdiction — such as with insurance policies issued in another state. It also happened with self-funded employer plans, where the employer, rather than the insurance company, pays the medical bills directly, putting the plan under federal rather than state oversight. Many large employers use self-funded plans, and employees may not be aware of it.

In other cases, the insurance department found that no specific law had been broken, so it said it could not intervene. In one case, for example, a provider separately billed a patient’s two plans — one commercial, the other Medicaid — both managed by the same insurer. The insurer’s system mixed up the billing codes between them, leading it to deny the claim and take back its payment. The state found no law had been broken.

The insurance department received 22 complaints in 2025 pertaining to recoupment, and of those, the insurance company was found in error in two. One was due to an incorrect provider address in the system, which caused the notice of recoupment to go to the wrong provider; the other was due to an incorrect coverage termination date, department spokesperson Barry Smith said in an email.

Greenfield said that generally, when there’s a contractual dispute, both the state and federal governments will defer to the contract. “They will say this is a contractual issue ... (and) by law we cannot get involved in a contractual dispute,” she said. “Each DOI is different. Some are very, very involved and provider-friendly — others I’ve found are merely paper pushers.”

While retroactive claim recoupment is typically more of a dialogue between insurers and providers, sometimes the fight spills over to patients.

That can happen when both insurers and providers seek the money directly from patients.

A few patients filed complaints with the Department of Insurance. In one case, an insurer paid a patient in full to reimburse them for a custom sleep apnea device, then months later reclassified the claim into a different coverage category and requested $3,750 back. The department found no violations of insurance law and told the complainant that if she continued to disagree, she should seek legal recourse.

Another complaint was filed by a patient who said her provider told her she owed more money after the insurer reprocessed a claim — 15 months after the original payment. The insurer told her this was because it had retroactively updated its contract with the provider. In a response letter to the insurance department, the insurer said the claim was reprocessed due to a contractual issue between it and the provider. The department forwarded the insurer’s response to the patient.

One protection for patients against surprise bills comes from federal rules that limit when balance billing can occur. Balance billing is when a provider bills patients for the difference between what the provider charged and what the insurance company actually paid.

The federal No Surprises Act, which took effect Jan. 1, 2022, bars out-of-network providers from balance-billing patients for emergency services, regardless of where the care is received. It also bars balance billing for non-emergency services provided by an out-of-network provider at an in-network facility.

Some instances of balance billing presenting a problem for patients, Killelea said, involve a patient having a different primary insurer than the one billed, a lapse in coverage, or an incorrect coverage effective date.

There are mechanisms providers use to avoid being left holding the bag. For example, some hospitals have patients sign a document before surgery stating that they will be responsible for any costs that aren’t paid, Killelea said. That’s done in scenarios where prior authorization — approval required by insurers before care is provided — is needed. Prior authorization is an agreement that a service is medically necessary but not a guarantee of final or full payment.

Greenfield said one instance in which a provider might bill a patient is when something was supposed to be covered under the contract between the insurer and the provider, but wasn’t.

So what do you do if you want to challenge a retroactive denial?

Typically, the route to take is to first reach out to the insurer and provider, then file an internal appeal with the insurer, and then, for a state-regulated plan, file a complaint with the state insurance department or another state agency that handles such complaints, Killelea said.

In North Carolina, insurance complaints — not just ones related to healthcare — can be filed with the Department of Insurance.

Smith said that when a complaint comes in, the department asks the insurer for basic details on the coverage, along with an explanation and justification for its position, which can include contract language, denial letters and explanation-of-benefits letters — the statements an insurer sends after processing a claim.

The agency then reviews the complaint, the insurer’s response and the supporting documents to determine whether the company complied with North Carolina insurance laws, regulations and policy provisions. If it finds a violation, the department requests corrective action. If a complaint falls outside its regulatory authority, Smith said, it advises the consumer on other steps they might take.

Health plans that largely fall outside the department’s purview include Medicaid, Medicare and self-funded plans.

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