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What happens if CMS notifies my group of a Medicare overpayment?

On Behalf of | Nov 24, 2020 | Health & Health Care Law |

The United States Centers for Medicare and Medicaid Services (CMS) defines a Medicare overpayment as one that exceeds a regulation and statute properly payment amount. Additional issues arise if the feds can establish that the provider was aware of the overpayment. Generally, the agency defines knowledge of a violation as actual knowledge, reckless disregard or intentional indifference to applicable law. If the government determines that your group has received an overpayment, it will expect you to pay back these funds.

What causes overpayments?

Medicare overpayments can occur for a variety of reasons. Three of the more common include incorrect coding when filing a claim, insufficient documentation to back up the claim and questions about whether or not there was medical necessity for the service.

How does CMS collect these funds?

CMS notes that the process often begins with a Medicare Administrative Contractor (MAC) demand letter. The agency may follow up with a phone call. Failure to respond will not make the issue go away. The agency may move forward with collection efforts, potentially including wage garnishment.

The MAC demand letter explains the reason for the alleged overpayment and a brief overview of the recipient’s rights. These rights include payment, rebuttal and appeal of the agency’s determination. Payment can be made immediately, or the provider can set up a recoupment plan that includes portions of future payments. Those wishing to rebut the determination must file a request within 15 calendar days from receival of the MAC demand letter. This does not cease recoupment efforts. The CMS generally cannot recopy payment during an appeal. The appeals process is more intensive and often includes a redetermination period. This can lead to reconsideration, a hearing, an official review by the Medicare Appeals Council and a Judicial Review by the U.S. District Court.

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