Your Options Following a Recovery Audit Overpayment Determination

 The Medicare Recovery Audit (RA) program, fomerly the Recovery Audit Contractor  program, ferrets out incorrect payments to physicians, hospitals, and other health care professionals. An appeal to an RA determination of overpayment is essentially the same as any other Medicare appeal. An RA initial determination is not appealed to the recovery auditor but to the Medicare carrier, i.e., to Novitas Solutions for Texas physicians.

 So what is the first step? The Centers for Medicare & Medicaid Services offers the options below to physicians who disagree with the recovery auditor's initial determination of overpayment.

Remember, one of a practice's best lines of defense for avoiding a RAC audit in the first place is a policy of regular coding and documentation audits, whether performed internally or by an outside consultant such as TMA Practice Consulting. Also, TMA's recorded one-hour webinar, , discusses self-audits, what to do with your findings, and how to get buy-in for corrective actions. 

Provider Options RA Overpayment Determination

   

Discussion Period  

 

Rebuttal  

 

Redetermination  

Which option should I use?  

 

The discussion period gives you an opportunity to give the recovery auditor more information showing why it should not initiate recoupment. It also gives the auditor an opportunity to explain the rationale for the overpayment decision. After reviewing the additional documentation you have submitted, the auditor could decide to reverse its decision. You will receive a letter will detailing the outcome of the discussion period.

 

The rebuttal process gives you an opportunity to provide a statement and accompanying evidence indicating why the overpayment action will cause a financial hardship and should not take place. A rebuttal is not intended to be a review of supporting medical documentation or a disagreement with the overpayment decision. A rebuttal should not duplicate the redetermination process. (See 42 CFR 405.374-375)

 

A redetermination is the first level of appeal. You may request a redetermination when you are dissatisfied with the overpayment decision. You must submit a redetermination within 30 days to prevent offset on day 41.

             

Whom do I contact?  

 

Connolly, Inc., the recovery auditor for Texas

 

Novitas (Jurisdiction H)  

 

 Novitas (Jurisdiction H)

             

Timeframe  

 

Day 1-40

 

Day 1-15

 

Day 1-120  Must be submit within 120 days of receipt of demand letter. To prevent offset on day 41, the you must file the redetermination within 30 days.

             

Timeframe begins  

 

Automated review: Upon receipt of demand letter

Complex review: Upon receipt of review results letter

 

Date of demand letter

 

Upon receipt of demand letter

             

Timeframe ends  

 

Day 40 (offset begins on day 41)

 

Day 15

 

Day 120

Updated Oct. 24, 2013

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