Medicare & Medicaid Recoupment Lawyer

Medicaid and Medicare Recoupment, Audits and Appeals

Healthcare providers that service the Medicare and Medicaid population are expected to know and comply with a complex and constantly evolving program. In today’s regulatory landscape – which closely scrutinizes waste, fraud, and abuse – errors in claims and billing practices can lead to audits and recoupment of overpayments.

Violations of healthcare laws identified in these audits can also result in Medicare fraud investigations and substantial penalties, including hefty fines, exclusions from Medicaid and Medicare, the loss of a professional license, and even criminal prosecution. With stakes as high as these, ensuring compliance and deftly handling audits and investigations becomes a top priority.

As one of the pre-eminent healthcare law firms in Texas, Hendershot Cowart P.C. draws from decades of experience to provide healthcare businesses and facilities with preventative legal counsel and defense against recoupment, lawsuits, fraud investigations, and penalties. Our services center on a comprehensive approach to billing practices and effective measures to mitigate exposure to penalties resulting from errors and violations.

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Learn more about our healthcare law services. Call (713) 909-7323 for an initial consultation.

Medicare or Medicaid Overpayments

As defined by the Centers for Medicare and Medicaid Services (CMS), a Medicare or Medicaid overpayment occurs when a healthcare provider receives payment that exceeds amounts properly payable under statutory law and regulations. When an overpayment is identified, it becomes a debt owed to the federal government that must be recovered. The underlying cause must also be identified.

How Do Medicare Overpayments Happen?

Overpayments may arise out of:

  • Administrative or billing errors
  • Documentation issues
  • Duplicate submission of the same service or claim
  • Furnishing and billing for excessive or non-covered services
  • Incorrect coding
  • Insufficient documentation
  • Medical necessity errors
  • Payment for excluded or medically unnecessary services
  • Payment to the incorrect payee

The best preventative measure to avoid overpayments is implementing direct and clear billing processes, airtight documentation, and procedures for identifying errors. However, it also helps to know what to watch for.

Common Examples of a Medicare Overpayment

  • Ambulance transports. For example, there are times when Medicare will cover ambulance transports. In such instances, the transport must be from and to a Medicare-approved point of service. If not, Medicare will seek recoupment. If an ambulance transports a person from their residence and delivers them to a Medicare-approved facility, the transport may not be covered by Medicare if the individual lives outside of the Medicare-approved facilities service area and there was a closer approved Medicare facility.
  • Billing for services not delivered. The most obvious overpayment is billing for services that were not actually delivered. Recently, a pharmacy and its owner agreed to settle allegations brought by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) for $1.3 million, in a case in which the OIG claimed the pharmacy and its owner submitted claims to Medicare Part D for brand name prescription drugs that it could not have dispensed based upon inventory records.
  • Improperly submitted claims. Recently, a physician practice providing otolaryngology services entered into a settlement with the OIG whereby the practice paid $200,630 in settlement to resolve allegations that the practice improperly submitted claims to Medicare and Texas Medicaid for hearing assessment services that were performed by unqualified technicians.

What to Do if You Receive a Medicare Demand Letter

If you receive a demand letter for recovery of an overpayment, contact a healthcare attorney immediately. Your attorney can advise on the best option for your practice and make sure you adhere to important deadlines.

How to respond to a Medicare overpayment demand:

  • You can make an immediate payment;
  • Request immediate recoupment (give instructions to recover the overpayment from future payments);
  • Submit a rebuttal; or
  • Appeal the overpayment by requesting a redetermination.

If you choose to submit a rebuttal statement to your Medicare Audit Contractor (MAC) – the multi-state, regional contractors responsible for administering both Medicare Part A and Medicare Part B claims – you must do so within 15 calendar days from the date of the demand letter.

This rebuttal gives you the opportunity to explain and show proof as to why the alleged overpayment is not accurate. An attorney experienced in responding to overpayment demands can help you prepare a credible rebuttal statement.

How Far Back Can Medicare Go to Recoup Payments?

Medicare contractors can review claims up to three years after the date they were filed. The look-back period for self-disclosed overpayments is six years from the date the overpayment was received. If a provider does uncover a Medicare overpayment, they must self-disclose the error within 60 days.

Requesting an Appeal to a Medicare Overpayment Decision

Alternatively, you or your Medicare audit defense lawyer can request an appeal. This is different from the rebuttal process.

There are five levels to a Medicare Part A and Part B appeals process. They are as follows:

  1. Redetermination by a Medicare Audit Contractor (MAC);
  2. Reconsideration by a Qualified Independent Contractor (QIC);
  3. Hearing by an Administrative Law Judge (ALJ) in the Office of Medicare Hearings and Appeals;
  4. Review by the Medicare Appeals Counsel; and
  5. Judicial Review in Federal District Court.

During the appeals process, CMS and its contractors are subject to certain limitations. When a valid first- or second-level appeal is received on an overpayment, CMS and MACs cannot recoup the overpayment until the decision on the redetermination and/or reconsideration is made. There are other certain applicable timetables which apply in such situations; therefore, the guidance of experienced legal counsel is important to protect your interest.

Also, it must be remembered that in the event a Medicare overpayment collection has been initiated, there will oftentimes be an investigation concurrently ongoing by the OIG for False Claims Act violations and/or fraud and abuse violations. Therefore, utilizing counsel that is familiar with each of these applicable regulations and who has had experience in dealing with the OIG and with Novitas is critical for the protection of your rights.

Comprehensive Counsel From Premier Healthcare Lawyers

From establishing sound practices and compliance to handling overpayment audits, requests for recoupment, appeals, and investigations over fraud, waste, and abuse, our legal team at Hendershot Cowart P.C. is equipped with the experience, insight, and resources to effectively provide all medical practices with the comprehensive counsel and tailored representation they need.

Our firm represents providers during all phases of audits, including those conducted by Medicare Audit Contractors (MAC) and Recovery Auditor Contractors (RAC) for overpayments, and Unified Program Integrity Contractors (UPIC), which specialize in investigating Medicare fraud. This includes guidance through matters involving demands for recoupment, which persist even when fraud investigations are initiated.

Preventative Legal Counsel

Preventative practices and proactive handling of Medicare and Medicaid overpayments are essential to avoiding audits, the overpayment recovery process, and recoupment.

To limit exposure to these risks, our firm focuses on the sentiment that “an ounce of prevention is worth a pound of cure,” and takes steps to pro-actively ensure sound practices and policies. These measures focus on compliance with applicable laws and regulations, along with assessment of risks providers face for possible violations. All measures are tailored to the unique circumstances of a practice and may include, among others:

  • Review of medical documents
  • Evaluation of current billing practices & service coding
  • Assessment of administrative policies
  • Analysis of data and error rate
  • Overpayment identification and subsequent protocol
  • Assessment of Stark compliance
  • Assessment of anti-kickback compliance

Given the complexities of Medicaid and Medicare, it is often the case that providers don’t knowingly violate the law. However, when violations occur, subsequent fraud investigations can create tremendous challenges, as well as exposure to penalties that threaten a practice and one’s professional livelihood.

Reporting Overpayments

In addition to establishing sound billing and administrative practices, providers should also focus on creating policies for proactively identifying overpayments and promptly reporting them. By law, health care providers must report overpayments and make arrangements to return them within 60 days from when they are identified. Proactive identification and handling of Medicare overpayments is essential to avoiding the overpayment recovery process and mitigating exposure to costly and time-consuming audits and recoupment.

Defense Against Fraud Investigations and Severe Penalties

In addition to proactive counsel and guidance through audits, overpayment issues, and the Medicaid / Medicare recoupment appeals process, our firm also provides defense against fraud investigations.

Our defense services focus on representing providers that have been notified of investigations through letters received by various entities – including the Office of Inspector General (OIG), Texas Department of Insurance (TDI), or Attorney General’s Office – or upon issuance of a warrant, subpoena, or unexpected shut down of a practice. Such investigations can be triggered by a number of things, including:

Whether an investigation stems from an audit conducted by TDI or a CMS contractor or other issues of inconsistencies and unusual patterns that may constitute Medicaid and Medicare Fraud, taking decisive action to consult an attorney immediately is critical to an effective defense. An early defense and representation during investigations and interviews are also critical to avoiding what can be severe and life-altering consequences, such as:

  • Civil fines that can amount to millions of dollars
  • Disenrollment from Medicaid and Medicare
  • Sanctions against a practice or professional
  • Medical board hearings and loss of license
  • Criminal charges and penalties

Contact Hendershot Cowart P.C. Today to Get Started

If you have questions regarding healthcare provider billing practices as they relate to Medicaid or Medicare, or wish to discuss a potential audit or fraud investigation, do not hesitate to speak with a member of our team about your rights, options, and the journey ahead.

Contact us for an initial consultation by calling (713) 909-7323. Our Houston-based lawyers serve clients throughout the state of Texas.

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