My facility is going through a Medicare UPIC review and received a significant number of denials followed by a demand letter requiring repayment. What are our options for appealing the decision and what is the interest rate that will apply if we aren’t able to immediately issue repayment?



When there is an overpayment of $25 or more, the MAC will initiate the overpayment recovery process by sending a demand letter. The demand letter should outline key information including the specifics of the overpayment (patient’s involved, dates, types of service, etc.,) as well as,  the recoupment process and repayment options, how interest will accrue and at what rate. The current interest rate is 11.5% and will be applied to unpaid overpayment balances beginning day 31 from the date of the demand letter. The demand letter will discuss rebuttal rights (due within 15 calendar days from the date of the demand letter), Administrative appeal rights and possibly instruct the Medicaid State Agency to withhold the federal share of any Medicaid payments until the full amount owed to Medicare is recouped. Notably, submitting a rebuttal does not stop recoupment activities; however, submitting a redetermination appeal by day 30 from the date of the demand letter will stop the initial recoupment process, but interest continues to accrue in accordance to 42 CFR 405.378. In the event that a redetermination appeal is received after day 30, but before day 120, the MAC is required to stop recoupment subject to Section 935 paragraph (f) (2) of the MMA when it receives and validates your appeal. In this case, the MAC will not refund money already recouped, but will not continue recoupment until the redetermination process is adjudicated. Following an unfavorable or partially favorable redetermination decision, a reconsideration appeal may be filed with the Qualified Independent Contractor (QIC) within 60 days from the redetermination decision letter date in order to stop the recoupment process. After the QIC’s unfavorable/partially favorable decision or dismissal, the recoupment process will resume (with interest) for any overpayment amount not previously paid in full regardless of whether the provider submits appeals at further appeal levels.

Amie Martin, CDP, CHC, RAC-CT, MJ

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