Recoupment of Overpayments
When you or your provider file a claim, TRICARE usually reimburses the proper amount. Sometimes we reimburse the wrong amount to you or your provider.
Regardless of fault, the Federal Claims Collection Act requires your regional contractor to try to recoup—or recover—any overpayments from you or your provider.
What are examples of mistakes that can result in an improper payment from TRICARE?
- An error calculating the allowable amount
- An error coding a procedure
- An error calculating the cost-shareA percentage of the total cost of a covered health care service that you pay. or deductible
- A duplicate payment
- Sending a payment to an incorrect payee
- Not getting data on all or part of the payment by other health insuranceHealth insurance you have in addition to TRICARE, such as Medicare or an employer-sponsored health insurance. TRICARE supplements don’t qualify as "other health insurance."
- An error in billing for the service
- Paying for services or supplies for a patient who’s not eligible for TRICARE
- Making payment for care from an unauthorized provider
- Making payment for a non-covered service or supply
- Paying for a service that wasn’t actually received by the patient
- Payment made for services that weren’t medically necessaryTo be medically necessary means it is appropriate, reasonable, and adequate for your condition.
This list isn't all inclusive.
How does the recoupment process work?
If we find an overpayment was made, your contractor sends the recipient of the payment (you or your provider) a written request for repayment. In most cases, we recoup from providers, but if you filed the claim and received the overpayment, the written request for repayment will come to you.
- The request explains your rights under the law including your right to appealThe action you take if you don’t agree with a decision made about your benefit.
- You should respond to this request within 30 days, even if you think it’s wrong
After 150 days, if you haven’t entered an agreement to repay the debt and your contractor hasn’t been able to recoup at least half the amount due, your contractor transfers your case to Defense Health Agency (DHA) Claims Collection.
DHA Claims Collection has several options for recoupment, which include:
- Legal action/litigation against you
- The amount owed can be taken from your military active or retired pay
- The amount owed can be taken from any federal funds owed to you
- Your debt can be referred to credit bureaus
- The amount due can be subtracted from future claims
Also, you may incur additional charges. Under extremely limited circumstances, we may compromise the debt. This is determined on a case-by-case basis.
What happens if my provider doesn’t repay the debt?
When we overpay to providers, we’ll only attempt to recoup from the provider—not you. The exception is cost-share or deductible errors, and certain eligibility cases. You’re generally responsible to only pay your applicable copaymentA fixed dollar amount you may pay for a covered health care service or drug. or cost-share for covered services. Your provider may attempt to bill you again. Because each scenario is unique, please contact your regional contractor if you have questions.
Recoupment with Other Health Insurance
If you have other health insurance and TRICARE paid first by mistake, your contractor will try first to recoup the payment from your other health insurance. If your other health insurance refuses to pay or doesn’t respond, the person who received the payment (you or your provider) is responsible. You can avoid this by always giving your other health insurance information to your contractor. >>Learn More
Last Updated 11/27/2018