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[TX] What defenses does a patient have when a health insurer demands repayment for a coordination of benefits error?
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Hello, I am being billed by my former health insurance provider for hospital bills back in 2025. They want payment back stating I had another primary insurance in 2025. It is over a year that they want a refund and the hospital cannot process the bills to the other insurance company. These bills equal to $15,000 and more for labor and delivery. I live in Texas and understand there are certain policy guidelines for health insurance companies to charge back. I'm not sure if my case would qualify. I did discuss with the hospital billing department and we've noticed there are two statements that the insurance company is wanting refunds for but I was never covered by a secondary insurance and didn't have my own personal primary insurance.
I understand how frustrating it must be to deal with unexpected billing issues from your former health insurance provider. Can you tell me if you have any documentation or correspondence from the insurance company regarding their claim for the refund?
The insurance company said they will fax the hospital a formal request for payment. But I haven't received anything via communication with the insurance company regarding payment or coverage. I am currently checking the EOBs from the insurance company for the dates they are requesting payment. I do have the itemized bills from the hospital with the dates the insurance wants a refund. We did notice that on a few of those dates the insurance company is requesting more money than what they actually paid the hospital for.
Have you already attempted to appeal this charge with your former health insurance provider or sought assistance from a consumer protection agency?
No I haven't yet. I was just informed of this situation this morning and not exactly sure what next step I can take. I've talked to the hospital billing department and they recommend I call the insurance company and clarify the dates and payment and call the hospital back afterwards to create a payment plan. I just want to see if there is anything I can do to not have to repay back these bills that were covered in the past but not anymore because the hospital never filed my primary insurance on a few of these dates and now it's become my responsibility to fix the problem.
Is there anything else the Lawyer should know before I connect you? Rest assured they'll be able to help with your billing dispute.
No.
Hello! My name is TJ, and I'm an attorney with over 20 years of experience. Thanks so much for the opportunity to assist you!
Your former insurer is claiming they paid as secondary when they should've been primary, or that another insurer should've been primary instead. Texas insurance law requires insurers to follow strict timelines and procedures for recovery claims. The fact that they're requesting more than they paid is a red flag. You've got potential defenses around whether they followed proper notice requirements and whether the claim is even timely after over a year. Did you ever receive formal written notice from them about being the secondary payer before they demanded repayment?
PS: I do my best to keep chats going in real time, but if there's a delay on my end, please don't worry. The chat doesn't close and I'll get back to you as soon as I can. There's no rush on your end either!
I was under the assumption that the hospital would have access to all my active insurances and filed them accordingly. I had gotten my physical primary insurance card in the mail and that is finally when my primary insurance card was finally filed with the hospital. My former insurer is wanting payment back from 11/2024 to 1/2025. My primary insurance was active 1/2025 to today and my insurance wasn't filed as primary until recently. I do not recall receiving any mail or communication from my former insurer asking about a secondary insurance.
This timeline actually works in your favor. Your former insurer covered you from 11/2024 through 12/2024, and your primary insurance didn't become active until 1/2025. For the dates your former insurer is demanding repayment (11/2024 through 1/2025), they were the primary insurer during the November and December portion, so they can't claim they paid as secondary for those dates.
The real issue is January 2025. If your primary insurance was active then but the hospital didn't file with them until recently, your former insurer might have a legitimate claim for January dates only. However, they still had to follow proper procedures to notify you about the overpayment and give you a chance to respond. The fact that you never received formal written notice from them is important. Texas law requires insurers to provide clear notice before demanding repayment, and they generally can't just demand money without going through that process first.
The other red flag you mentioned, that they're requesting more than they actually paid, suggests their calculation might be wrong. That's worth investigating.
When you do contact your former insurer, do you know whether you'll be asking them to provide documentation showing exactly what they paid for each date and how they calculated what they're claiming you owe?
Here's a more detailed timeline and information of the insurances involved if this will help. Sorry it's a lot of info. I was covered by my former insurer through my husband's work from 9/1/22 to 9/30/2025. These are the dates of service they want repayment for:
- 07/11/2024, requested payment $1,151.12
- 11/04/2024, requested payment $1,464.39, paid hospital $1,264.39
- 01/23/2025, requested payment $12,655.73, paid hospital $9,762.12
Before I was on my husband's plan I was covered on my mom's health insurance until I was 26, in September of 2023. My primary insurance through my employer didn't start until 1/01/2025 and continues today. I have a secondary insurance through my husband that changed carriers, starting 10/01/2025.So I'm not exactly sure what other insurance my former insurer is disputing I was covered by in 2024, because I was no longer eligible for my parents' insurance and my personal insurance wasn't active until January of 2025.
I will be sure to ask my former insurer for documentation for the dates of service they are wanting repayment for, because what they are requesting and what they paid on the itemized bill doesn't equal the same amount.
This timeline clarifies a lot, and it actually strengthens your position significantly.
Looking at the three dates your former insurer is targeting, the July 2024 charge is the most problematic for them. You were covered by your former insurer at that time with no other primary insurance, so they can't claim they paid as secondary. They'd have to explain why they're demanding repayment a year and a half later for a claim they already processed and paid. That's a timing issue that works against them. This lines up with (TX Ins Code § 1301.132), which generally requires an insurer seeking to recover an overpayment from a health care provider to do so, with written notice explaining the basis for the request, within 180 days of the date the payment was received. A demand made well outside that window is on shaky legal ground.
For the November 2024 date, same situation. You had only your former insurer's coverage. There was no other primary insurance. They're requesting $1,464.39 but only paid $1,264.39, which means they're asking you to cover the difference between what they claim you owe and what they actually paid out. That doesn't make sense unless they're claiming they overpaid, but their own numbers show they underpaid the hospital.
The January 2025 charge is their strongest argument since your new primary insurance started January 1st. However, even here, the hospital didn't file with them until recently. Your former insurer can't demand repayment without proving they paid as secondary when they should've been secondary, and they need to follow proper notice procedures first. There is also a coordination of benefits principle at play here: under (TX Ins Code § 1301.134), when a secondary payer pays a portion of a claim that should have been paid by the primary payer, the overpayment can generally only be recovered from the insurer that was primarily responsible, not automatically passed on to you or the patient.
The core problem with your former insurer's entire claim is that they're not explaining what other primary insurance they think existed in 2024. You've documented that you had none. That's a major gap in their position. When you contact them, ask them specifically which insurance they believe was primary on each date. If they can't name one, their claim falls apart.
Did I cover what you needed, or do you have other questions about how to approach this with your former insurer? Thank you for laying out all those details. That really helps.
I will be sure to ask my former insurer about how they calculate their numbers for the repayment and who they believe I was covered by in 2024. I honestly can't recall my former insurer emailing or mailing out any paperwork asking if I had a secondary insurance. Do I need to bring it up and ask if they ever sent the paperwork or followed the proper notice procedure?
Yes, absolutely bring it up. Ask your former insurer directly whether they sent you any formal notice about the overpayment and when. Ask them to provide copies of any notices they claim to have sent. Texas law requires insurers to give you proper written notice before demanding repayment, and if they can't produce documentation that they did, that's a strong defense for you.
Also ask them to explain in writing which insurance they believe was primary on each date. Getting their answer in writing protects you and makes it clear they're making claims they can't back up.
Is there anything else you'd like to clarify before you reach out to them?
Thank you! That clarified my last question and I feel more prepared to call my former insurer now.
You're very welcome, and I'm glad I could help! Feel free to reach out if you need anything else.
Sorry, one last question. When I was leaving the billing department at the hospital they said my former insurer was going to fax them a request for repayment, would that qualify as them notifying me?
No, that doesn't count as notifying you. A fax to the hospital is notice to the hospital, not to you. Insurance companies are required to notify the patient directly, usually by mail or email. The hospital receiving a request for repayment doesn't satisfy that requirement. You need your former insurer to show they sent notice directly to you at your address or email. That's an important distinction and another point in your favor.
I called the reference number the hospital gave me for who they have been speaking with regarding my former insurer wanting a refund for their claims processed, and it is a third-party recovery company representing my former insurer. They said it was my husband's secondary coverage that was the primary insurance during the 2024 invoices, which doesn't make sense since we didn't switch to that carrier until 10/01/2025. I brought that up and the third-party recovery company said that is what is showing on their system. However, I've called and double-checked with the hospital and they can confirm that we were not covered by that plan during the 2024 invoices, so I'm not exactly sure how they are getting their information for the third party. All the information they were able to email over was:
"Hello, please have the provider bill the new primary carrier as primary, attaching a copy of the former insurer's EOB and a copy of our refund request letter that we sent to them. Most carriers will make an exception to their timely filing deadline where it can be shown that there was a coordination of benefits error, and the claim was billed in a timely manner to the secondary carrier in error. Thank you and have a good day!"
I called my former insurer directly afterward to confirm if I had any conflicting insurance policies during those three coverage dates and the representative said there were no denials or disputes with any other insurers during those service dates. I explained my situation to the representative and they gave me a reference number to provide the hospital and third-party recovery company. She did confirm that there are no notes of any disputes of claims or formal notice of overpayment on our account. She also emailed me the EOB of each service date. I will follow up with an email to my former insurer requesting this information in writing, I did record the phone call and I double checked that Texas is a one-party consent state in terms of recordings. The hospital said they would give me a copy of the formal refund request from the third party if or when they fax it over because I haven't received anything else otherwise.
I did ask my former insurer if the hospital or third party is being persistent about payment who do I contact via them, and they said to call their number in regard to the reference number they provided. The hospital took the reference number I provided and said they will give the information to the third party to call with my former insurer. I'm not exactly sure what else I need to do to help myself. It seems like a little bit of a scam of sorts but I don't want to be liable for paying money back to a third party when my former insurer had no clue what I was talking about when I called.
You've done excellent work here. The fact that your former insurer itself has no record of disputes, denials, or formal overpayment notices on your account is huge. That directly contradicts the third-party recovery company's claim. The third party is operating on false information, and your former insurer's own representative confirmed it.
Keep all documentation: the EOBs your former insurer emailed, your recording of that call, the hospital's confirmation you weren't on that other plan in 2024, and the third party's email showing they're claiming the wrong insurance was primary when it wasn't. Don't pay anything to the third-party recovery company. If they persist, you have a clear paper trail showing their demand is based on incorrect information that even your former insurer disputes.
You're in a strong position. Anything else you need, or are you good to move forward from here?
Thank you! I'll keep this documentation on hand and I think I'm good to move forward unless I hear anything else from the hospital or the third-party recovery company to proceed with payments. I appreciate your help and feel less stressed about this situation, thank you!
You're welcome. You handled this exactly right, and you've got a solid foundation if anything does come up. Good luck with this.
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