Understanding Basics Of Medicare Overpayment

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Understanding Basics Of Medicare Overpayment
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Understanding Basics Of Medicare Overpayment

• What is Medicare Overpayment?
• An overpayment is a payment made to a provider
  exceeding amounts due and payable according to
  existing laws and regulations. Identified
  overpayments are debts owed to the federal
  government. Laws and regulations require CMS
  recover overpayments. This fact sheet describes
  the overpayment collection process. A Medicare
  overpayment exceeds regulation and statute
  properly payable amounts. When Medicare
  identifies an overpayment, the amount becomes a
  debt a healthcare provider owes the federal
  government. Federal law requires CMS recover all
  identified overpayments. Medicare overpayments
  happen because of incorrect coding insufficient
  documentation medical necessity errors and
  processing and administrative errors. The
  Medicare Secondary Payer (MSP) program is in
  place to ensure that Medicare is aware of
  situations where it should not be the primary, or
  first, payer of claims. In certain situations,
  after a Medicare claim is paid, CMS receives new
  information indicating Medicare has made a
  primary payment by mistake. Based on this new
  information, CMS takes action to recover the
  mistaken Medicare payment.
• Medicare Overpayment Collection Process
• After provider or billing team identifies the
  overpayment, they must report and return a
  self-identified overpayment to Medicare within
• 60 days of overpayment identification
• 6 years from overpayment receipt, generally known
  as the lookback period
• If applicable, the cost report due date

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Understanding Basics Of Medicare Overpayment
When provider get an overpayment of 25 or more,
applicable Medicare Administrative Contractor
(MAC) initiates overpayment recovery by sending a
demand letter requesting repayment. A MAC demand
letter explains overpayment reason(s), interest
accrual begins if the overpayment isnt repaid in
full within 30 days, immediate recoupment request
options, Extended Repayment Schedule (ERS)
request options, rebuttal rights, and appeal
rights. Response by Providers Office Providers
office can review this demand letter and check
for details provided in demand letter to verify
actual overpayments. Based upon review providers
office can take following steps Immediate
Payment Follow the demand payment letter
directions. Request Immediate Recoupment Occurs
when Medicare recovers an overpayment by
offsetting future payments. MAC may recoup a
partial payment (for example, a percentage of
payments recouped) or a complete recoupment. Upon
providers request, MAC can begin recoupment
immediately by following the demand letter
instructions. Initiating immediate recoupment
applies to all current and future debts, unless
otherwise specified.
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Understanding Basics Of Medicare Overpayment
Request Standard Recoupment MAC automatically
begins standard recoupment according to the
Overpayment Debt Collection Activities schedule.
If the debt becomes delinquent, interest may
accrue. Request an ERS If provider cant make
the full overpayment in the required timeframe,
follow the instructions in the MAC ERS demand
letter. Rebuttal Submit a rebuttal within 15
calendar days from the date of receiving MACs
demand letter. Explain or provide evidence why no
recoupment should occur. The MAC promptly
evaluates your rebuttal statement. Appeal In
case of disagreement with an overpayment
decision, provider or providers representative
can request an appeal. Medicare Part A and Part B
has 5 appeal levels
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Understanding Basics Of Medicare Overpayment

• Redetermination is the first appeal level after
  the initial Part A and Part B claims
  determination. MAC takes a second look at the
  claim and supporting documentation. A MAC
  employee uninvolved in the initial determination
  makes the redetermination.
• Reconsideration by a Qualified Independent
  Contractor (QIC).
• Hearing by an Administrative Law Judge or Review
  by an Attorney Adjudicator at the Office of
  Medicare Hearings and Appeals (OMHA).
• Review by the Medicare Appeals Council.
• Judicial Review in U.S. District Court.
• In case, provider fails to pay in full, he will
  get an ITR letter 6090 days after the initial
  demand letter. The ITR letter advises to refund
  the overpayment or establish an ERS. In case of
  non-compliance, MAC refers the debt for
  collection.
• Medisys Data Solutions is a leading medical
  billing company providing complete assistance in
  medical billing and coding. If you need any
  assistance in billing Medicare, contact us at
  info_at_medisysdata.com/ 302-261-9187.

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