Optum/United Healthcare is in the process of sending out overpayment notices to clinical social workers. These notices inform providers of overpayments made by Optum/United Healthcare and request reimbursement.
Overpayment recovery, commonly referred to as "clawbacks," is a complex issue and regulations vary significantly from state to state. (Information on specific state laws may be found on the Crossroads Health website. NASW makes no representations as to the accuracy of the information contained in this website. Social workers are encouraged to look up the relevant state statute to find the most up to date information.) Impacted social workers may also want to consult an attorney to understand their rights and responsibilities.
Social workers who received a notice from Optum/United Healthcare have a right to appeal the request for repayment. To initiate an appeal, providers should act promptly and adhere to the following steps:
Respond Within the Given Time Frame: The notices provide the timeline for appeal. Most notices provide up to 30 days from the date the overpayment notice was issued to file an appeal.
Prepare Documentation: Include a copy of the notice received from Optum/United Healthcare. Also, enclose the detailed list of alleged overpayments provided by them.
State Your Case Clearly: Clearly articulate the reasons for the appeal providing relevant details and supporting documentation to strengthen the arguments.
Potential Reasons to Appeal
Although state law differs and each situation may vary, we have found that courts in California, Nebraska, Mississippi, and Texas have cited the below reasons for prohibiting a clawback if the payment resulted from the insurer’s mistake. Impacted social workers may consider including any or all of these reasons when preparing their appeal.
Error by the Insurance Company: Where insurance company made the mistake of paying beyond its responsibility, and the provider made no misrepresentations, had no knowledge or notice of the insurer’s mistake, and extended services based on the assignment of payment by the insured, this could form a basis for appeal.
Undue Burden and Unreasonableness: Should the insurer’s repayment demand impose an undue financial or operational burden on the provider, or if the provider deems the demand unreasonable, this could be another ground for appeal.
Good Faith Services: Where the provider provided services in good faith, and relied on the pay rates confirmed and provided by the insurance company at the time, this fact could also help in the appeal as it emphasizes the legitimacy of the provider’s actions.
While these suggestions may serve as starting points, it is crucial for impacted social workers to undertake a thorough review of the specific laws governing insurance claim clawbacks in their respective states. Additionally, if the social worker has a contract with Optum/United Healthcare, it is important to review the contractual agreement to understand the relevant terms. Most importantly, seeking professional legal counsel is highly recommended to ensure that the response to this repayment demand is formulated with expert guidance.
If you need assistance with finding an attorney in your state, we recommend reaching out to your state’s bar association to find an attorney who is well-versed in healthcare law and the specifics of overpayment recovery in your jurisdiction.
The information contained is provided as a service to members and the social work community for educational and information purposes only and does not constitute legal advice. We provide timely information, but we make no claims, promises, or guarantees about the accuracy, completeness, or adequacy of the information contained on this website or links to other sites. Transmission of the information is not intended to create, and receipt does not constitute, a lawyer-client relationship between NASW, or the author(s) and you. NASW members and online readers should not act based on the information provided. Laws and court interpretations change frequently. Legal advice must be tailored to the specific facts and circumstances of a particular case. Nothing reported herein should be used as a substitute for the advice of competent counsel.