Section 935 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) provides limitations on the recoupment of Medicare overpayments. This means that when an overpayment is subject to the limitation on recoupment protections, Medicare will not begin overpayment collection (or will cease collections that have started) when it receives a valid request for a redetermination (first level of appeal), or a reconsideration (second level of appeal).
Full Answer
Is there a 935 overpayment recoupment?
Section 935 Overpayment Recoupment Process. Section 935 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) provides limitations on the recoupment of Medicare overpayments. The information below describes how you will be notified of an overpayment and the processes available to respond to these notifications.
What happens if Medicare overpays you?
Overpayment Definition A Medicare overpayment exceeds regulation and statute properly payable amounts. When Medicare identifies an overpayment, the amount becomes a debt you owe the federal government. Federal law requires we recover all identified overpayments. Medicare overpayments happen because of:
What is section 935 of the MMA?
Section 935 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) provides limitations on the recoupment of Medicare overpayments.
Are Medicare payments made in response to a demand subject to 935?
Payments made by a provider in response to a demand are not recoupments. Recoupment is the recovery by Medicare of any outstanding Medicare debt by reducing present or future Medicare payments and applying the amount withheld to the indebtedness. Therefore, payments made in response to a demand are not subject to Section 935 interest.
What is a 935 payment?
The result of the original claim reversal and the 935 claim may either be an overpayment amount for the full amount of the claim payment or a partial amount. On the same RA, the resulting overpayment amount is then added back to the RA total net reimbursement in the Adjust to Balance field.
What is a 935 appeal?
Limitation on recoupment (935) process Accruement continues until debt is fully satisfied. Fully satisfied means paid in full or overturned by appeal.
What is a Medicare overpayment?
A Medicare overpayment is a payment that exceeds regulation and statute properly payable amounts. When Medicare identifies an overpayment, the amount becomes a debt you owe the Federal government. Federal law requires the Centers for Medicare & Medicaid Services (CMS) to recover all identified overpayments.
Does Medicare refund overpayment?
When Medicare identifies an overpayment, the amount becomes a debt you owe the federal government. Federal law requires we recover all identified overpayments. When you get an overpayment of $25 or more, your MAC initiates overpayment recovery by sending a demand letter requesting repayment.
What is the difference between reconsideration and redetermination?
Any party to the redetermination that is dissatisfied with the decision may request a reconsideration. A reconsideration is an independent review of the administrative record, including the initial determination and redetermination, by a Qualified Independent Contractor (QIC).
How do you win a Medicare appeal?
Appeals with the best chances of winning are those where something was miscoded by a doctor or hospital, or where there is clear evidence that a doctor advised something and the patient followed that advice and then Medicare didn't agree with the doctor's recommendation.
Why would an overpayment be made?
An overpayment is defined as any payment that is larger than the invoice's outstanding amount. This can occur if the wrong amount is paid, or if an invoice is accidentally settled twice.
Why did I get a Medicare refund?
For many, this money is taken out of their Social Security checks. It's possible seniors are being overcharged for Medicare and may be entitled to a refund.
What should you do if Medicare overpays you for patient treatment?
If Medicare Finds the Overpayment You can reply using the Immediate Recoupment Request Form, request immediate recoupment via the eRefunds or Overpayment Claim Adjustment (OCA) features in the WPS-GHA portal, or wait for Medicare to implement their standard recoupment process.
How do I get a refund for overpayment?
There are two main ways to file a refund claim for overpayment of taxes. The first is to file an amended return that corrects the error you had previously made. The other option is to file a Form 843 Claim for Refund and Request for Abatement.
What is the lookback period for overpayments?
within six yearsThe rule also states that an overpayment must be reported and returned if it is identified within six years of the date it was received. This time period is generally referred to as the “lookback” period.
How long does Medicare have to request a refund?
3 calendar yearsWhat is the timeframe in which Medicare may request return of an overpayment? For Medicare overpayments, the federal government and its carriers and intermediaries have 3 calendar years from the date of issuance of payment to recoup overpayment.
How long does Medicare overpayment interest accrue?
Interest will accrue on an overpayment, if not repaid within 30 days of the original demand date.
How to stop Medicare from recouping again?
A provider can stop Medicare from recouping again by filing the next level of appeal (reconsideration with the QIC (Qualified Independent Contractor)). Once a valid and timely reconsideration is filed on an overpayment eligible for the limitation of recoupment the following will happen:
How long does interest accrue after overpayment?
If the overpayment is not made, interest will continue to accrue for each subsequent full 30-day period. If the overpayment amount is reduced, interest will be recalculated and adjusted for the overpayment amount from the original demand date, regardless of the date the revised overpayment amount is determined.
What is Medicare 935?
Section 935 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) provides limitations on the recoupment of Medicare overpayments. This means that when an overpayment is subject to the limitation on recoupment protections, Medicare will not begin overpayment collection (or will cease collections that have started) when it receives a valid request for a redetermination (first level of appeal), or a reconsideration (second level of appeal). The following provides additional information about this process.
Can Medicare refund be withheld?
A refund will be issued for any collections on the debt. The refund may be withheld and applied to other debt that you might owe, and any excess will be released to you. Partial reversal – The claim will be adjusted and shown on the Medicare remittance advice but will not impact reimbursement.
What happens if Medicare overpayment exceeds regulation?
Medicare overpayment exceeds regulation and statute properly payable amounts. When Medicare identifies an overpayment, the amount becomes a debt you owe the federal government. Federal law requires we recover all identified overpayments.
What is an overpayment?
An overpayment is a payment made to a provider exceeding amounts due and payable according to existing laws and regulations. Identified overpayments are debts owed to the federal government. Laws and regulations require CMS recover overpayments. This fact sheet describes the overpayment collection process.
What is SSA 1893(f)(2)(A)?
SSA Section 1893(f)(2)(A) outlines Medicare overpayment recoupment limitations. When CMS and MACs get a valid first- or second-level overpayment appeal , subject to certain limitations , we can’t recoup the overpayment until there’s an appeal decision. This affects recoupment timeframes. Get more information about which overpayments we subject to recoupment limitation at
What is reasonable diligence in Medicare?
Through reasonable diligence, you or a staff member identify receipt of an overpayment and quantify the amount. According to SSA Section 1128J(d), you must report and return a self-identified overpayment to Medicare within:
Who is the contractor for Medicare overpayment?
Once a determination of an overpayment has been made, the amount of the overpayment is a debt owed to the United States Government, via Novitas Solutions , as one of its Medicare contractors.
What are some examples of overpayments?
Examples of overpayments where you could be liable include, but are not limited to, the following: Payment exceeds the reasonable charge for the service. Duplicate payments of the same service (s) Incorrect provider payee. Incorrect claim assignment resulting in incorrect payee.
What is a post-pay denial of claims for Medicare Part A?
Determined post-pay denial of claims for benefits under Medicare Part A for which a written demand letter was issued (a letter informing the provider of the overpayment determination as
How long does it take for Medicare to stop recouping?
You can also stop Medicare from recouping any payments at a second point in the recoupment process by filing a valid request for reconsideration with the QIC within 60 days of the appropriate notice/letter.
Does Medicare adjust claims in the normal manner?
As a result of post-pay reviews or MSP recoveries and during the Part B claim adjustment process, Medicare carriers and MACs, including DME MACs, will adjust claims in the normal manner.
Can a Medicare contractor rebuttal a recoupment?
States that the provider may submit a rebuttal statement (which is not an appeal request) to any proposed recoupment action and the Medicare contractor will review it and consider whether to proceed or stop the offset (remember that they may elect to continue recoupment);
Does Medicare contractor recoup overpayment?
Whether or not the provider, physician or supplier subsequently appeals the overpayment to the ALJ, the Medicare Appeals Council, or Federal court, the Medicare contractor will continue to recoup until the debt is satisfied in full.
Limitation on recoupment (935) process
The information below outlines the process for the 935 recoupment due to changes from CMS through change request (CR) 6183 -- limitation on recoupment of section 935 for provider, physicians and suppliers overpayments.
Contractor timelines and audit explanations
The information below outlines the process for the 935 recoupment due to changes from CMS through change request (CR) 6183 -- limitation on recoupment of section 935 for provider, physicians and suppliers overpayments.
Immediate Recoupment For 935 Overpayments
- Providers have the opportunity to request immediate recoupment to avoid making payment by check and/or avoid the assessment of interest if the immediate recoupment pays the debt in full before day 31. An immediate recoupment is considered a voluntary repayment. The request for immediate recoupment should be received in writing at least 16 days from...
Results Letters
- Overpayments may be the result of a post-pay review or a Medicare Secondary Payer (MSP) recovery. Post-pay reviews may be done by any of the Medicare Contractors. Based on the overpayment determined by the post-pay review or MSP recovery, CGS will adjust the claim and apply the limitation on recoupment. A demand letter explaining the reason for the overpayment …
Rebuttal Process
- An opportunity for you to rebut the recoupment action is available by submitting a statement within 15 days of the notice. The rebuttal process is not considered an appeal and does not stop recoupment activities. Rebuttal statements should explain or provide evidence about why the recoupment should not take place. Rebuttal statements can be mailed to: Please send rebuttal s…
Redetermination
- Recoupment will proceed on day 41 from the demand letter unless you submit a valid redetermination that stops the recoupment process. A valid redetermination request: 1. Must be received by the 30th day from the date of the demand letter to stop recoupment of the 935 overpayment 2. May be received within 120 days from the date of the demand letter, recoupmen…
Reconsideration
- If you are not satisfied with the outcome of the redetermination, you may file a reconsideration with the Qualified Independent Contractor (QIC) within 60 days of the redetermination notice. When CGS is notified by the QIC of your valid and timely request for reconsideration, recoupment of the overpayment will stop, or not initiated if it has not yet begun. In addition: 1. The amount al…