Retroactive Denials

Retroactive DenialsWhat is it?

A retroactive denial is the reversal of a previously paid claim, through which the member then becomes responsible for payment. Claims can be denied retroactively for various reasons. The most common is because coverage was retroactively termed.

What this means for patients:

Retroactively denying a patient’s coverage is incredibly dangerous and can lead to high out-of-pocket costs and adverse health effects. Under current Florida state law, there is no limitation on an insurer's ability to recoup payments already made, even in cases where no fraud is alleged. This system leaves patients and their well-being unprotected and at the whims of insurers.

FSR Policy:

The Florida Society of Rheumatology supports legislation that would ensure that Florida health plans include a provision prohibiting retroactive denials when, on the date the provider renders the prior approved service: The patient is eligible, the patient’s condition hasn’t changed, and the provider submits an accurate claim that matches the information submitted by the provider in the approved PA request.