Standard debt collectors dial phones. We fight audits.
If you have received a demand letter from an insurance payer asking for money money back—or worse, if they are already withholding funds from your current checks to pay off an “old debt”—you are facing Recoupment.
This is not a collections issue. It is a legal and compliance dispute. Treating it like standard bad debt is why most practices lose these battles.
At NexaCollect, we don’t just ask them to stop; we audit the auditors.
Need a Collection Agency? Contact us
Why Switch? The “Takeback” Letter is Not a Bill.
Most collection agencies operate on a simple model: they harass patients to pay $50 copays. But when UHC, Aetna, or a Medicare MAC demands $50,000 back because of an “alleged coding error” from two years ago, a standard agency is useless. They cannot argue ERISA law, and they cannot audit a CPT code.
The Landscape Has Changed in 2026:
Insurance payers are now using AI-driven “Predictive Overpayment” models. In 2024 alone, initial claim denial rates spiked to 11.8%, and automated recoupment demands increased by over 20% in the commercial sector. They are using algorithms to find patterns and demand bulk refunds, hoping you are too busy to fight back.
The Nexa Difference:
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Force Multiplier for Billing Staff: Your billing team is built to submit new claims, not fight forensic legal battles on old ones. We handle the heavy lifting so they don’t burn out.
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Reputation-Safe Dispute Resolution: We argue on regulatory and contractual grounds—never aggression. This preserves your contract status with the payer while protecting your bank account.
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The “Investigation” Shield: Under the revised CMS 60-Day Rule (effective Jan 1, 2025), proper investigation protocols can pause the refund clock for up to 180 days. We know how to trigger these pauses to buy you time and leverage.
The “Takeback” Danger Zone: 3 Risks of Waiting
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Statute of Limitations: Many states have strict “clawback” windows (often 12–24 months). If you don’t initiate the recoupment professionally and quickly, the money is legally gone.
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Provider Resistance: Providers often view recoupment as a “hidden tax.” Our mediators bridge the gap, explaining the data clearly to reduce friction.
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Offsetting Complications: While future payment offsetting is common, it can lead to reconciliation nightmares. Direct recovery through Nexa keeps your books clean.
Q&A: The Executive Guide to Recoupment Defense
Q: Why does a collection agency letter work when my rebills failed?
A: It triggers a “Statutory Countdown.” When you simply resubmit a claim, it goes back into the automated claims queue—often to be denied by the same algorithm. A Legal Demand Letter is different. It is classified as a “Pertinent Communication” under state Unfair Claims Settlement Practices Acts.
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The Shift: It forces the carrier to route your claim out of the automated queue and into the “Dispute Resolution” or “Legal” department.
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The Timer: In most states, once this letter is received, the carrier is legally required to respond within a stipulated timeframe (typically 15 to 30 days). If they ignore it, they risk “Bad Faith” litigation penalties.
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The Result: Your case is finally prioritized and reviewed by a human specialist, not a bot.
Q: Is it legal for them to just take money out of my current checks?
A: Often, yes—but they must follow strict procedural rules. This is called “offsetting.” However, under ERISA laws, if the original plan was self-funded (which many employer plans are), the insurer may not have the right to offset funds from a different patient’s claim to pay for the first one. We audit every offset to ensure they aren’t robbing Peter to pay Paul illegally.
Q: How far back can they go?
A: It depends on your state and your contract.
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Commercial Payers: Usually limited by state “Lookback Periods.” For example, Florida generally limits recoupment to 30 months, while Texas prompt pay laws have a 180-day limit for certain clawbacks. If your contract is silent, general state statutes of limitation (often 4-6 years) might apply.
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Medicare (RAC Audits): Generally 3 years, but can go back further if “fraud” is alleged (which they use loosely).
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The Defense: We frequently get demands thrown out simply because they violate the “Lookback Period” by even one day.
Q: Can we fight a “Medical Necessity” recoupment?
A: Absolutely. These are the most common and the most beatable. Payers often use automated “black box” algorithms to deny care as “not medically necessary” without a human doctor ever reviewing the chart. We force them to produce the clinical credentials of the reviewer. If an algorithm made the decision, we challenge the validity of the audit itself.
Recent Results:
We do not use hypothetical examples. These are real scenarios handled by specialized defense teams.
Scenario A: The “AI Algorithm” Mass Sweep
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The Threat: A mid-sized Surgical Center received a bulk demand for $420,000. A major commercial payer’s AI algorithm flagged every instance of a specific CPT modifier used over the last 18 months, claiming it was “unbundled” incorrectly.
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The Defense: We utilized the No Surprises Act dispute framework and clinical coding guidelines to prove the AI failed to account for the specific anesthesia time units associated with the procedure.
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The Result: The demand was reduced to $12,500 (a 97% reduction) after we proved the vast majority of claims were compliant.
Scenario B: The “Silent” Offset
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The Threat: An Out-of-Network provider noticed their revenue dropped by 15% overnight. The payer had silently begun withholding $15,000 per month from current checks to satisfy a disputed overpayment from 2021 regarding “Usual and Customary” rates.
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The Defense: We issued a legal demand citing a breach of ERISA procedural requirements, specifically the failure to provide a “Full and Fair Review” before commencing recoupment (citing Montanile v. Board of Trustees precedents).
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The Result: The offsetting stopped immediately. The $85,000 already withheld was returned to the provider, and the original dispute was moved to mediation.
Ready to Stop the Bleeding?
A recoupment demand is a time-sensitive legal threat. Every day you wait is a day the “Lookback Period” might expire or the “60-Day Rule” might lock you in.
Do not let them audit you into the red.