Notes on payer behavior

The insurer says it overpaid you: recoupment rules in Florida, and when to say no

Clearia · September 2026 · recoupment, Florida

An overpayment letter feels like a bill you can't argue with. It is a claim, and like any claim it can be wrong, late, or both. On Florida fully insured and HMO business the insurer has twelve months from the date it paid to ask for money back, it has to tell you why, and you have the right to contest before anything is taken. A large share of recoupment demands fail one of those three tests. Check before you refund.

The Florida rule

Section 627.6131(18), Florida Statutes (and the HMO parallel in 641.3155(16)), says a claim for overpayment against a physician, osteopath, chiropractor, podiatrist, or dentist "must be submitted to the provider within 12 months after the health insurer's payment of the claim" and "may not be permitted beyond 12 months," except from providers convicted of fraud. For other provider types the general lookback is 30 months. The insurer has to make the demand to your designated location with "a written or electronic statement specifying the basis for the retroactive denial or payment adjustment" and identify the claims. You then have 40 days to pay, deny, or contest, and a written contest must go out within 35 days stating the contested portion and the reason. Subsection (10) says the whole section "may not be waived, voided, or nullified by contract," so a payer agreement claiming a longer lookback doesn't override it. For services on or after January 1, 2026, chapter 2025-45 adds psychologists to the 12-month rule.

The carve-outs matter: none of this applies to self-funded employer plans under ERISA, to Medicare Advantage, to federal employee plans, or to workers' comp. Check the plan's funding status before you cite the statute.

Where recoupments hide

Most practices never see a recoupment letter. They see a smaller deposit. Payers take the amount out of a later remittance, against unrelated claims, and record it in the 835's provider-level adjustment segment, the PLB, where posting software dumps it into an unapplied bucket. On Florida state-regulated plans that shortcut is itself restricted: subsection (6)(a)3 says the insurer "may not reduce payment to the provider for other services unless the provider agrees to the reduction in writing or fails to respond to the health insurer's overpayment claim as required." An offset you never agreed to, on a demand you answered in time, is disputable on its own. A quarterly read of PLB amounts by payer is the only way most offices find out it happened. Where the PLB sits in the file.

Before you refund, check four things

1. The date. Payment date to demand date. Past twelve months on a state-regulated plan, the demand is barred unless fraud is alleged.
2. The reason. "Overpayment" isn't a reason. Coordination of benefits, duplicate payment, eligibility retroactively terminated, a fee schedule correction: each has its own defense. On retroactive ineligibility, subsection (11) bars an insurer from denying a paid claim for that reason "more than 1 year after the date of payment."
3. The math. Recompute the claim at the contracted rate. Payers sometimes "correct" a claim to a rate below the contract, turning a recoupment into an underpayment.
4. Whether it was already taken. Match the letter to the PLB entries. Paying a demand that was already offset means paying twice.

How to contest

In writing, within 35 days of receiving the demand, identifying the contested portion and the specific reason, with the statute cited where it applies and the recomputation attached. If you ask for information, the insurer has 35 days to send it and you then have 45 days to pay or deny. Respond inside those windows: a provider who "fails to respond" loses the protection against offsets. If the offset was already taken against unrelated claims, the dispute asks for those claims to be repaid, not just the demand withdrawn. Keep the letter as short as an appeal: claim identifiers, the demand, why it fails, what you're asking for.

When to refund

When the demand is timely, the reason is real, and the math is right. True duplicates and genuine COB errors happen, and paying them promptly keeps the relationship clean for the disputes that matter. The discipline that makes recoupment defense work is the same one that makes recovery credible: contest what's wrong, pay what's right, and know which is which before the money moves.