When an insurer asks for money back, first find out which rules bind it. That decides how long it had to ask and whether it can take the money while you appeal. A PPO or HMO plan regulated by Texas has to send written notice within 180 days after you received the payment and give the specific reasons, and it may not recover the money until all of your appeal rights are exhausted. A self-funded employer plan, Medicare and Medicaid each work differently.
A recoupment rarely arrives as one claim, which is why the first question is worth an afternoon. Optum's 2024 notices asked behavioral health clinicians to repay claims from January 1, 2022 to February 24, 2024 (Behavioral Health Business, April 26, 2024). A Georgia counselor, Tracy Hooper, described an insurer that found it had paid from the wrong plan: "And then they came back for all of the money" (Georgia Public Broadcasting, March 4, 2025).
This post covers Texas law and federal Medicare rules as they read on the day it was published. It isn't legal advice, and your network contract may add terms of its own.
Which rules apply to the letter?
Start with the client's insurance card. Both Texas sections sit in chapters about plans and the providers in their networks, so they speak to in-network claims. The Texas Department of Insurance tells consumers that "We don't regulate most health plans" and that "If it has 'TDI' or 'DOI' on it, we can help you" (TDI, updated December 17, 2025). The letters mark a plan issued under the Insurance Code's HMO and PPO chapters (28 TAC §21.3003). A plan run by a large insurer can still be self-funded by the employer, so the card tells you more than the insurer's name. A card without the letters usually belongs to a self-funded employer plan, and TDI says those "are regulated by federal law and are under the jurisdiction of the U.S. Department of Labor" (TDI, self-funded plans).
But Optum's notices reached back more than two years. For a claim paid by a Texas-regulated PPO or HMO, a request made that long after payment would miss the 180-day notice the statute requires. For a self-funded plan, the same request may be allowed by your network agreement.
What does a Texas plan's letter have to say?
Section 1301.132 lets an insurer recover an overpayment only if two things are true. It sent written notice "not later than the 180th day after the date the physician or provider receives the payment", and the notice includes "the basis and specific reasons for the request for recovery of funds". And the provider has not arranged to repay "on or before the 45th day after the date the physician or provider receives the notice." Section 843.350 says the same for HMOs.
If you disagree, the plan "shall provide the physician or provider with an opportunity to appeal", and it "may not attempt to recover the overpayment until all appeal rights are exhausted." So what are the 45 days for? They are the time you have to decide, claim by claim, whether to repay or to appeal.
A letter that lists claims with no reason for each, or that arrives more than 180 days after you were paid, does not meet the statute's conditions. Say so in writing and cite the section. Keep the envelope or the portal's timestamp, because the dates are the whole argument.
A letter you can adapt
Send it by a route that records the day it arrived, and keep a copy. Fill in the parts in parentheses, and cut any paragraph that does not apply. List only the claims you are appealing, and repay the rest.
Re: your overpayment request dated (date), member (ID), claims (claim numbers)
We received your request on (date). We dispute recovery of the claims listed below, and only those, and appeal under Texas Insurance Code §1301.132(b) (§843.350(b) for an HMO). Under that subsection, recovery may not be attempted until all appeal rights are exhausted. Please confirm in writing that no amount will be offset from future payments while this appeal is open.
For claims (numbers), we received payment on (dates), more than 180 days before your notice, so the notice does not meet §1301.132(a)(1).
For claims (numbers), the notice does not state the basis and specific reasons for recovery as §1301.132(a)(1) requires. Please send them for each claim.
How does Medicare differ?
Medicare's contractors work on longer clocks. A contractor can reopen a claim "within 1 year from the date of the initial determination or redetermination for any reason" and within 4 years for good cause (42 CFR 405.980). Once it sends a demand, it "can begin recoupment no earlier than 41 days from the date of the initial overpayment demand", and it must stop "upon receipt of a timely and valid request for a redetermination" (42 CFR 405.379). The same pause applies to a reconsideration. If you appeal further, to an administrative law judge, "recoupment remains in effect". File the redetermination as early as you can, and before day 41, so it is on record before recoupment begins.
Medicare began paying marriage and family therapists and mental health counselors on January 1, 2024 (CMS), so a practice that has enrolled its counselors since then may be meeting these rules for the first time.
How to answer the letter
- Write down the day the letter arrived. For a Texas-regulated plan, the 45 days run from that day.
- For each claim the letter lists, find the day the original payment reached you. A claim paid more than 180 days before the notice is one the Texas sections do not let the plan recover. The sections name no exception for fraud, but other law may reach it, so treat any letter that alleges fraud as one for your attorney.
- Read the reason given for each claim and check it against the claim and the note. A wrong rate, the wrong plan, a second insurer and missing documentation each call for a different answer.
- Decide claim by claim whether to repay or to appeal. Send the appeal in writing, cite the section and ask the plan to confirm it will not offset payments while the appeal is open.
- Watch every remittance until the letter is settled. A plan that takes the money back usually does it as a provider-level adjustment on a later payment, not as a change to the original claim, so it is easy to miss.
- If a Texas-regulated plan takes money before your appeal is decided, TDI's prompt-pay page sends providers with "claim-related issues" to its Provider Resources page and to "a link on how to file a complaint" (TDI, updated August 6, 2026).
Should a clinician's pay absorb the clawback?
Decide this before the next letter arrives, with your attorney, and write the answer into each clinician's pay terms. Passing clawbacks straight to the therapist is one of the reasons Texas supervisor trainer Kate Walker gives for why counselors leave group practices (Kate Walker Training, October 17, 2025). A clinician who loses part of a paycheck over a billing error two years old, made by the insurer, has a reason to look elsewhere. The post on why therapists leave group practices covers the other reasons.
What to do this week
- Pull every recoupment letter from the last 12 months and sort them by the plan type on the client's card.
- For each letter from a Texas-regulated plan, compare the notice date with the date you were paid for each claim on it.
- Put a date 45 days after each open letter on the calendar of whoever handles billing.
- Ask your biller for every provider-level adjustment on last quarter's remittances, and match each one to a letter. Question any offset that has no letter first.
- Decide with your attorney whether a clawback can touch clinician pay at all. In Texas a deduction from wages needs the employee's written authorization, which the post on paying therapists per session covers.
Sources
- Texas Insurance Code §1301.132, Overpayment, recovery from a preferred provider, added 2005.
- Texas Insurance Code §843.350, Overpayment, recovery by a health maintenance organization, added 2003.
- 28 Texas Administrative Code §21.3003, standard identification cards.
- Insurance card examples, Texas Department of Insurance, updated December 17, 2025.
- Self-funded plans, Texas Department of Insurance, updated June 23, 2023.
- Prompt pay, Texas Department of Insurance, updated August 6, 2026.
- 42 CFR 405.980, reopening of initial determinations.
- 42 CFR 405.379, limitation on recoupment.
- Optum Behavioral Health releases the first of two mass overpayment notices, Behavioral Health Business, April 26, 2024.
- So-called insurance clawbacks are driving Georgia mental health therapists to private pay, Georgia Public Broadcasting, March 4, 2025.
- Why counselors are leaving group practices and what comes next, Kate Walker Training, October 17, 2025.
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