Date
Medicare Part B
Overpayments
3101 S. Woodlawn
Denison, TX 75020
RE: Voluntary Refund of Overpayment
Dear Medicare Overpayment Department:
As a routine compliance measure, this physician office conducts regular analysis of our billing, coding and claims filing procedures. Our intentions are to fully comply with the rules and regulations set forth by Medicare regarding claims payment and coverage policies and is clearly understood by all employees of this practice.
As a result of our internal analysis and compliance program, we have identified the following overpayment and are in good faith voluntarily refunding all monies collected in error. Billing errors that may have been made by our office have been identified and resolved. We would like to ensure that Medicare understands this was merely a billing error and we are committed to remaining in good standing with the Medicare program.
The specific claim information is as follows:
Patient Name:
Patient Medicare Number:
Claim Number:
Amount of Claim:
Reason for Refund:
Check number ___________ in the amount of $_________ dated ____________ is attached to this letter and represents a refund from _______________________, Medicare provider number ________________.
Should you have additional questions, please do not hesitate to contact me at _____________________; otherwise, I will assume this issue has been resolved favorably and accurately.
Sincerely,
Name
Title
Attachments: Refund Check and Medicare Remittance Notice
Last Updated On
August 24, 2015
Originally Published On
March 23, 2010