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HHS states my physician group chose the wrong code. Now what?

The United States Department of Health and Human Services (HHS) has stated physician groups throughout the country are mistakenly choosing the wrong code when it comes to charging Medicare for services provided to stroke patients.

What is the problem?

According to a recent report from the HHS Office of the Inspector General (OIG), physicians are failing to use the right code when a stroke patient is transferred from Medicare to Medicare Advantage. More specifically, the OIG states physician groups are making an error when using acute stroke diagnosis codes. This has led to inflated payments.

Is this serious?

In short, yes. The government states the error has led to over $14 million in overpayments.

What does this mean for physician groups?

The government may contact physician groups who bill for stroke services and accuse the groups of receiving an overpayment. Those who believe these accusations are false can fight the agency’s claims. In these situations, physicians’ groups can move forward with an overpayment appeal.

How does the overpayment appeals process work?

The process generally begins with an investigation. The physician group can provide evidence to challenge the claim of an overpayment, this is officially referred to as the reconsideration phase of the overpayment appeals process. If this is not successful, the physician group can move forward with a hearing. During the hearing, the group will have an additional opportunity to challenge the claim of an overpayment. If the hearing proves unsuccessful, the group can continue the appeals process all the way to court. The last step involves taking the case to the federal district court.  

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