After pay denial

[Bill11]

oregon state,

my health insurance agreed to pay a medical claim. the claim has already been paid. The doctor that performed the procedure has now informed me that my insurance is trying to deny the claim, after it was already paid for. i don't see, legally, how the insurance company can ask for the money back after they have already paid the claim.

any advice would be appreciated,

thanks

 

[cbg]

What reason is the insurance company giving? That would make a difference.

 

[Bill11]

the insurance company feels they made a mistake in paying the claim. they are calling the procedure "cosmetic".

i don't see how this would make any difference, if they already paid it how can they ask for the money back from the doctor; the doctor was paid 4 months ago.

 

[I AM ALWAYS LIABLE]

My response:

Four months is irrelevant. If the procedure was cosmetic, then that's what it is. The doctor may have given the insurance company an incorrect Code for the actual procedure in order to get paid. But, when the actual surgical records were reviewed, the insurance company discovered the error; i.e., wrong code.

So, have you discussed this matter with both the doctor and the insurance company to get to the bottom of this problem ? If so, what was said by each of them, besides the conclusion that you have stated on this thread ?

IAAL