To refund or not refund, that is the question?

To refund or not refund, that is the question?

After all, you have done the work and the patient has not been compliant in wearing their brux guard. Do you really have to refund?  Here is a case history to read and remark upon:

“A patient had a porcelain crown done in 2014. The crown was covered by insurance and it paid out $405.  The patient paid their portion with care credit. This patient has severe bruxism and refused to wear a night guard. The first crown cracked and the doctor redid the crown at no charge to the patient. The same thing happened 2 more times and the patient is so dissatisfied that they are leaving the practice to have the crown done elsewhere. The doctor knows that the crown will not be covered again due to frequency limitations. But, the office is wondering if they can have the crown removed from the patient’s insurance history; send the money back to the insurance, so that the patient will be able to have the new crown billed by the new provider. Will this send up any red flags to the insurance company when the patient has the new claim submitted? What are my options?”

Option 1

Yes, if they refund the money, then the claim will be removed from the history.  At least that’s my experience with this kind of situation.

You will need to submit a corrected claim removing the crown from treatment and a detailed narrative explaining why you are removing the crown from treatment. I can honestly say that this is a difficult and challenging task however it can be done. Once the insurance receives the information they will send a request for refund for what they have paid. Once they received their refund they will remove the crown as being completed.

Option 2

I think it depends on the insurance company.  If you send the refund initially with a narrative as to why you are issuing the refund, then it would be dealt with faster, rather than waiting for the insurance to ask for the refund.  Sometimes that can take months to get the letter of reimbursement.

Option 3

I have done both and I found the direct to provider route easier for everyone mainly because some insurance companies can be difficult regarding payment, removal of the history and time it takes for insurance to do all of this.   I have had insurance come to me asking for proof a service was not performed before (it was an extraction) so I would be hesitant of all the issues that may arise.

 Provider to provider may be appreciated more in her community and even the patient (sooner replacement possible). I personally would suggest the office manager reach out to the new office and ask their preference.

What do you think of this and have you ever had this issue?

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