Medicare / Medicaid Overpayments

There may come at time when you or your healthcare company receives an overpayment notice from the Medicare or Medicaid program.

These overpayments can occur for a number of reasons: The provision of medically unnecessary services, diagnosis coding errors, system pricing errors, errors in eligibility status, and duplicate submissions, to name a few.

These overpayments generally are identified via audits conducted by the various contractors with the Centers for Medicare and Medicaid Services (CMS) such as those with Recovery Audit Program and Zone Program Integrity Contractors (ZPIC).

Once CMS identifies an overpayment, there are strict guidelines that must be adhered to when it comes to the appeals and recoupment process.

The Medicare Administrative Contractor can start with a demand letter for repayment, with the provider being given 41 calendar days after the date of the first demand letter to start making repayment. During this process, all Medicare payments will stop until full payment is made, which can have a devastating financial impact on a practice.

In recent years, auditors have begun to rely more heavily on extrapolation estimates to determine overpayments. By doing so, they have attempted to force many providers to repay most, if not all, of the money believed to have been overpaid in multiple years. That can result in damages reaching into the hundreds of thousands, or even millions of dollars.

The good news is there is an appeals process and a provider can submit a rebuttal statement to the Medicare Administrative Contractor within 15 calendars days from the date of the overpayment determination.

The Health Law Offices of Anthony C. Vitale has extensive experience representing clients in audits and overpayments and we can represent your interests through all of the stages of the overpayment appeals process in an effort to achieve the most successful results.