Recovery Auditor Determinations - Agree or Disagree - JA DME

Recovery Auditor Demand Letter

• CMS Change Request (CR) 7436 - Recovery Audit Program MAC-issued Demand Letters
• Supplier Options - Recovery Auditor Overpayment Determination

Agree with Recovery Auditor Decision

• Complete and fax the Immediate Recoupment Form to Noridian. View Form Instructions
• Submit request via fax with copy of demand letter,
• Allow offset on Day 41 (interest accrues 31 days from date of demand letter)

Disagree with Recovery Auditor Decision

Recovery Auditor redeterminations follow the normal Medicare appeals process. If a supplier has received a demand letter identifying an overpayment from a Medicare Recovery Auditor and believes it is incorrect, the decision may be appealed. It is important to understand the deadlines that exist at all the levels of appeal.

Below are the steps suppliers should take.

1. Contact Recovery Auditor to Request a Discussion Period - Discussion period offers opportunity for supplier to provide additional information to Recovery Auditor to indicate why recoupment should not be initiated. It also offers opportunity for Recovery Auditor to explain rationale for overpayment decision. Discussion period has two different start times, depending on whether it is for an automated or complex review
   • Automated Review: Discussion period begins when supplier receives an Initial Findings letter from Recovery Auditor. Receipt of that letter begins discussion period. Supplier has 30 days from date of Initial Findings letter to request a discussion period
   • Semi-Automated and Complex Review: Discussion period begins when supplier receives Review Results letter from Recovery Auditor. Receipt of that letter begins discussion period. Supplier has 30 days from date of Review Results letter to request a discussion period
2. Initiate the Rebuttal Process - Under existing regulations 42 CFR section 405.374, (debtors) providers, physicians and suppliers have 15 days from date of Recovery Auditor demand letter to submit a rebuttal statement to Noridian. A rebuttal should be submitted only on rare occasions of financial hardship. Rebuttal process allows supplier opportunity to provide a statement and accompanying evidence indicating why overpayment action will cause a financial hardship and should not take place. A rebuttal is not intended to review supporting medical documentation nor disagreement with overpayment decision. A rebuttal should not duplicate Redetermination process. Noridian will provide debtor decision in writing within 15 days of request; however, rebuttal statement is not an appeal of the overpayment determination and it will not delay/cease recoupment activities
3. Request a Redetermination
   • View Appeal Levels

Important Facts

• Recoupment(s) Halted - When a supplier submits a redetermination within 30 days of receiving a demand letter identifying an overpayment from a Recovery Auditor
• Interest Accrues - With or without a redetermination 31 days from date supplier receives the overpayment letter, unless full repayment is made before this time
• Time Limit to File Initial Redetermination - 120 days (from overpayment determination date)
• Redetermination Elements Required - The following elements must be present when requesting a redetermination: beneficiary(s) name; Medicare Health Insurance Claim Number(s) of beneficiary(s); specific service(s) and/or item(s) for which Redetermination is being requested; specific date(s) of service; and name and signature of person filing Redetermination request
• Documentation - When submitting a redetermination, include all relevant medical documentation to support appeal

If suppliers have not done so already, update contact information with the Recovery Auditor. This will assist receiving requests for documentation timely.

Note: The DME Supplier Contact Center can only answer general questions about the Recovery Auditor program. Any other questions should be directed to the Recovery Auditor contractor.