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  4.  → What happens if my business is accused of a Medicare overpayment?

What happens if my business is accused of a Medicare overpayment?

The United States Department of Justice (DOJ) recently accused New York health service company Cigna of over $1 billion in Medicare overpayments from 2012 through 2017. The feds state the insurance provider intentionally misrepresented health conditions to justify higher payments.

These types of allegations are not uncommon. The government is watching for insurance providers, physician practices and any group that bills Medicare to make these types of errors. It will use software programs to dig through records and claims to look for any potential red flags and encourage workers to report against their employers with qui tam or whistleblower suits that can provide reporting workers with a portion of any winnings. And these strategies work. Earlier this year the government put together a similar case against Anthem.

What if the government accuses my organization of a Medicare overpayment?

It is important to note that the government’s determinations of an overpayment are not final. Your organization can appeal the government’s claim that you received an overpayment. The Medicare and Social Security Acts allow providers to disagree with these claims through a series of administrative appeals.

To begin this process, request a redetermination. This must generally be completed within 120 days after you receive the notice of overpayment. If received within 30 days, you can prevent the recoupment process. If received after 30 days, Medicare will cease recoupment efforts. However, it may already have recouped some of the alleged overpayment and is unlikely to return these funds. During this phase, a contractor completes a review of the initial determination. You can generally submit additional evidence at this stage to support your claim.

If the redetermination process does not go in your favor, you may request reconsideration. If this process is unsuccessful, you may appeal to an Administrative Law Judge. This results in a hearing, similar to a lawsuit, involving the use of witnesses and review of evidence. If this fourth step fails to result in a satisfactory finding, you can reach out to the Medicare Appeals Council for further review.

There are strict deadlines and rules for each step of the process. As such, those considering the appeals process are wise to seek counsel for guidance throughout the appeal.