Professionals – Claim applied to previous calendar year’s deductible is reversed/voided, what happens?
Hey all, analyst at a large provider here. We had a recent situation that caused discussion and I wanted to get your take on it.
Review has uncovered claims from a previous calendar year that should not have been submitted to patients' Part D or MAPD plans. Without going into details, the services were indeed rendered, but the claims in question did not meet the criteria to be billable.
No payment was remitted to us from the PBMs because the entire allowable on the claims was applied to patients' deductibles which were collected at the time of service.
When these claims are voided, those amounts are going to be reversed off of the patients' TrOOP costs obviously. What we are wondering is, once those amounts are voided, could this cause a cascading effect of claim adjustments on later dates of service for those patients?
For instance, if a claim from January 2023 fulfilled the patient's yearly deductible and claims in February and forward were then processed at 80/20, would the payer then go back and adjust the February claim, potentially causing a greater patient responsibility amount?
submitted by /u/Kind-Consequence2526
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