CMS Pub. 100-08, ch. pim83exhibits, § 7.4

Request Repayment of Overpayments

(Rev. 213, Issued: 06-29-07, Effective: 07-30-07, Implementation: 07-30-07)

SAMPLE LETTER--MEDICARE PART B

DATE:

PROVIDER NAME: INTERMEDIARY NAME:

PROVIDER ADDRESS: INTERMEDIARY ADDRESS:

PROVIDER NUMBER:

OPENING:

Dear XXXXX:

Thank you for your cooperation during the comprehensive medical review conducted at your

facility on ___________. Based on this review, we have reopened claims in accordance with the

reopening procedures at 42 CFR 405.841 and have determined that you have been overpaid in

the amount of ____________. We hope the following information answers any questions you

may have.

REASON FOR REVIEW

This review was conducted because our analysis of your billing data showed that you may be

billing inappropriately for services. (Include in this paragraph any additional details on why the

provider was selected for the review.)

HOW THE OVERPAYMENT WAS DETERMINED

A randomly selected sample of ________ claims processed from ________ to ________ was

selected for review to determine if the services billed were reasonable and necessary and that all

other requirements for Medicare coverage were met. Medical documentation for the selected

claims was reviewed by our medical review staff.

Based on the medical documentation reviewed for the selected claims, we found that some

services you submitted were not reasonable and necessary, as required by the Medicare statute,

or did not meet other Medicare coverage requirements. Along with our claims payment

determination, we have made limitation on liability decisions for denials of those services subject

to the provisions of §1879 of the Social Security Act (the Act). Those claims for which we

determined that you knew, or should have known, that the services were noncovered have been

included in the results of this review. In addition, we have made decisions as to whether or not

you are without fault for the overpayment under the provisions of §1870 of the Act. Those

claims for which you are not without fault have been included in the results of this review. We

projected our findings from the claims that we reviewed to the universe of claims processed

during the time frame mentioned above.

GENERAL PROBLEMS IDENTIFIED IN THE REVIEW AND/OR CORRECTIVE ACTIONS

TO BE TAKEN

This review has shown that you are not following published Medicare guidelines and policies in

submitting claims for necessary and reasonable ________ services. (Reference any provider

specific education that occurred regarding these services.) Because of these identified problems,

your future claims for _______ may be subject to prepayment review until you correct your

billing.

WHY YOU ARE RESPONSIBLE

You are responsible for the overpayment if you knew or had reason to know that service(s) were

not reasonable and necessary, and/or you did not follow correct procedures or use care in billing

or receiving payment, and you are found to be not without fault under §1870 of the Act.

A list of specific claims that have been determined to be fully or partially noncovered, the

specific reasons for denial, identification of denials that fall under §1879 of the Act and those

that do not, the determination of whether you are without fault under §1870 of the Act, an

explanation of why you are responsible for the incorrect payment, and the amount of the

overpayment is attached. (Enclosed a list of the specific claims and an explanation of fault for

each. See the example within this exhibit.)

An explanation of the sampling methodology used in selecting claims for review and the method

of overpayment estimation is attached. (Enclose an explanation of the sampling methodology.)

WHAT YOU SHOULD DO

Please return the overpaid amount to us by _______________(date) and no interest charge will

be assessed. Make the check payable to Medicare Part B and send it with a copy of this letter to:

__________________Address

IF YOU DO NOT REFUND IN 30 DAYS

In accordance with 42 CFR 405.378, simple interest at the rate of _______ will be charged on

the unpaid balance of the overpayment beginning on the 31st day. Interest is calculated in 30-day

periods and is assessed for each full 30-day period that payment is not made on time. Thus, if

payment is received 31 days from the date of final determination, one 30-day period of interest

will be charged. Each payment will be applied first to accrued interest and then to principal.

After each payment, interest will continue to accrue on the remaining principal balance at the

rate of ______.

We must request that you refund this amount in full. If you are unable to make refund of the

amount at this time, advise this office immediately so that we may determine if you are eligible

for an extended repayment schedule. (See enclosure for details.) Any extended repayment

schedule (where one is approved) would run from the date of this letter.

RECOUPMENT AND YOUR RIGHT TO SUBMIT A REBUTTAL STATEMENT

If payment in full is not received by (specify a date 40 days from the date of the notification),

payments to you will be withheld until payment in full is received, an acceptable extended

repayment request is received, or a valid and timely appeal is received.

You have the right to submit a rebuttal Statement in writing within fifteen days from the date of

this letter. Your rebuttal Statement should address why the recoupment should not be put into

effect on the date specified above. You may include with this Statement any evidence you

believe is pertinent to your reasons why the recoupment should not be put into effect on the date

specified above. Your rebuttal Statement and evidence should be sent to:

Carrier Name, Address, Telephone #, and Fax #

Upon receipt of your rebuttal Statement and any supporting evidence, we will consider and

determine within 15 days whether the facts justify continuation, modification or termination of

the overpayment recoupment. We will send you a separate written notice of our determination

that will contain the rationale for our determination. However, recoupment will not be delayed

beyond the date Stated in this notice while we review your rebuttal Statement. This is not an

appeal of the overpayment determination, and it will not delay recoupment based on §1893(f)(2)

of the Act. If put into effect, the recoupment will remain in effect until the earliest of the

following: (1) the overpayment and any assessed interest are liquidated; (2) we obtain a

satisfactory agreement from you to liquidate the overpayment; (3) a valid and timely appeal is

received; or (4) on the basis of subsequently acquired evidence, we determine that there is no

overpayment.

Whether or not you submit a rebuttal Statement, our decisions to recoup or delay recouping, to

grant or refuse to grant an extended repayment schedule, and our response to any rebuttal

Statement are not initial determinations as defined in 42 CFR 405.803, and thus, are not

appealable determinations. (See also, 42 CFR 401.625 and 405.375(c).)

YOUR RIGHT TO CHALLENGE OUR DECISIONS

This letter serves as our revised determination of the claims listed in the attachment. If you

disagree with this determination, you may request a redetermination within 120 days of the date

of this letter (unless you show us otherwise, receipt is presumed to be five (5) days from the date

of this letter). You have the right to raise the same issues under this procedure as you would

have in the context of non-sampling claims determinations of Part B services billed to the Fiscal

Intermediary, and overpayment recovery. (See 42 CFR 405.801, et seq. and 42 CFR 405.701, et

seq.) You may ask for a redetermination of the denials for which you are determined to be liable

under §1879 of the Act or for which the beneficiary is determined to be liable under §1879 of the

Act, but declined, in writing, to exercise his/her appeal rights, and determinations for which you

are found to be not without fault under §1870 of the Act. You may also challenge the validity of

the sample selection and the validity of the statistical projection of the sample results to the

universe. (Refer to the appeals procedure in your Provider Manual Section __________ for

further details.)

IF YOU HAVE FILED A BANKRUPTCY PETITION

If you have filed a bankruptcy petition or are involved in a bankruptcy proceeding, Medicare

financial obligations will be resolved in accordance with the applicable bankruptcy process.

Accordingly, we request that you immediately notify us about this bankruptcy so that we may

coordinate with both the Centers for Medicare & Medicaid Services and the Department of

Justice so as to assure that we handle your situation properly. If possible, when notifying us

about the bankruptcy, please include the name the bankruptcy is filed under and the district

where the bankruptcy is filed.

If you have any questions regarding this matter, please contact _________ at ___________.

(Provide correspondence address.)

Thank you in advance for your prompt attention to this matter.

Sincerely,

Enclosures