There are a variety of situations that may cause a supplier to owe Medicare money on previously paid claims. Debt may be the result of a Noridian initiated claim edit correction, the Recover Auditor findings, a Comprehensive Error Rate Testing (CERT) contractor finding, or as a result of an Office of Inspector General claim review. Part A and B providers and DME suppliers have one year to file a claim which may cause situations in which a claim was paid that would normally have been denied if all of the patient's services were filed in a sequential order. This may include Skilled Nursing Facility or Hospital admissions. Other situations that may cause debt include changes to the beneficiary's eligibility as maintained by the Social Security Administration (e.g., date of death, cancelled policy, election of a Managed Care Plan).
CMS requires the DME MAC to request refunds on overpayments of $25 or more. If a supplier owes several small overpayments, each of which is less than $25, the total amount owed will be aggregated at the end of the month. If the total amount equals $25 or more, a refund will be requested. Although not requested by the DME MAC, refunds of less than $25 will be accepted. If a lump sum refund would cause a severe financial hardship, repayment may be accepted over an extended period. The supplier must submit specific documentation to support the extended repayment plan request.
Refund of Excess Recoupments
"If specific patient/HIC/Claim # information is not provided within 60 days of the receipt of the refund, no appeal rights can be afforded with respect to this refund. Providers/ physicians/ suppliers and other entities that are submitting a refund under an OIG Self-Disclosure Protocol are not afforded appeal rights as stated in the signed agreement.
Contractors shall only refund excess recoupments when no other outstanding accounts receivable exists, or written documentation/evidence clearly supports that Medicare is not entitled to the money or was not the intended recipient of the refund check."
A supplier may submit a rebuttal when there is good cause to believe the DME MAC should not withhold claim payments to offset a recouped account receivable.
Common reasons to submit a rebuttal may include, but are not limited to:
- A check has been submitted for payment.
- The overpayment was created in error.
- The overpayment was created for a full, instead of a partial claim adjustment, and a clarification is included with the rebuttal statement.
A rebuttal may be requested as a business letter or memo, as there is no formal form required. To ensure correct processing:
- Clearly indicate "Rebuttal" in the subject line or first sentence of the document and on the envelope.
- Clearly state the reason for the rebuttal and include any supporting documentation, e.g., cashed checks.
- Include a copy of the original overpayment letter with the rebuttal statement. If the original overpayment letter is not available, the following information may be included in the rebuttal itself:
- Supplier's name
- National Provider Identifier (NPI) or Provider Transaction Access Number (PTAN)
- Account receivable number [also known as the document control number (DCN)]
- Beneficiary's Health Insurance Claim Number (HICN)
- Date of service
Overpayment rebuttals should be mailed to Noridian.
The rebuttal will be reviewed and a response will be sent to the supplier in writing.
- Recovery Auditor Overpayments - See Recovery Auditor Determinations - Agree or Disagree
Last Updated Jun 16, 2016