Tuesday, April 23, 2019

Quality to the Next Level


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Overpayment Issues

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1-1741958467 - Friday, May 12, 2017

In this case, the ALJ set aside an extrapolated overpayment on the basis that, in the context of ambulance services denied under 1861(s)(7), an extrapolated overpayment violated the due process rights of non-sampled beneficiaries in the universe of claims because they had not been notified of their potential financial liability. The Council found that the “ALJ’s refusal to apply the valid extrapolated overpayment in this case is contrary to the binding authority of HCFA Ruling 86-1.”

Referral Document

Appeals Council Decision

 

 

 
1-994717993 - Friday, May 10, 2013
Rationale for the Referral:  The ALJ erred in waiving recoupment under § 1870 of the Social Security Act for supplies furnished by a DMEPOS supplier that were subject to SNF consolidated billing. Specifically, a supplier’s reliance on contemporaneous information in the Common Working File on the date of service does not constitute reasonable care in billing for, and accepting, payment, as it is contrary to CMS instructions and does not provide a reasonable basis for assuming that the payment was correct. Furthermore, a supplier’s remedy if it is overpaid in these situations is to obtain payment from the SNF.

NOTE: The Appeals Council labels its decision with a different "master" ALJ appeal number, although the AdQIC referral and Appeals Council decision are for the same nine appeals.

Referral Document

Appeals Council Decision

 

 
1-828654453 - Friday, May 10, 2013

Rationale for the Referral: The ALJ erred in invalidating the extrapolation on the basis that the beneficiary, and not the claim, should have been used as the sampling unit, as Medicare Program Integrity Manual sampling instructions expressly state sampling units may be individual claims.

Referral Document

Appeals Council Decision

 
1-952830085 - Friday, May 10, 2013

Rationale for the Referral: Section 1870 of the Social Security Act addresses waiver of recoupment of overpayments. Section 1870 does not apply in a case where the claim was denied initially and no overpayment occurred.

Referral Document

Appeals Council Decision

 
1-960553171 - Friday, May 10, 2013

Rationale for the Referral:  The ALJ erred in waiving recoupment of an overpayment to a supplier because recovery would be “against equity and good conscience” according to § 1870(c) of the Social Security Act. Section 1870(c) allows waiver of recovery to an individual beneficiary, not to a supplier. The ALJ also erred in finding the DME supplier to be “without fault” regarding the overpayment on the basis that the Medicare contractor failed to educate the Appellant that Medicare will not pay for surgical dressings ordered by a chiropractor.

Referral Document

Appeals Council Decision

 
1-994899347 - Monday, May 6, 2013

Rationale for the Referral: Section 1870 of the Social Security Act addresses waiver of recoupment of overpayments. Section 1870 does not apply in a case where the claim was denied initially and no overpayment occurred.

Referral Document

Appeals Council Decision

 
1-802121621 - Monday, May 6, 2013

Rationale for the Referral: The ALJ erred in setting aside the extrapolated overpayment on the basis that the strata were ill-defined, and because there was “no evidence of exploratory information completed before the extrapolation.” Additionally, HCFA Ruling 86-1 and Program Integrity Manual instructions provide that the remedy when individual claim denials have been reversed is for the contractor to recompute the projected overpayment based on the revised claim determinations. The ALJ’s determination that some of the sampled claims were not overpaid does not provide a basis for setting aside the entire extrapolated overpayment. Finally, the preponderance of evidence does not support the ALJ’s decision that the sampling methodology was statistically invalid.

Referral Document

Appeals Council Decision

 
1-814718434 - Monday, April 1, 2013
Rationale for the Referral: If the PSC used a sample methodology that complies with the provisions of CMS Ruling 86-1 and the Medicare Program Integrity Manual, then the question is not whether another statistician might construct a different or more precise sample, using a different sampling methodology or stratification. Rather, “an appeal challenging the validity of the sampling methodology must be predicated on the actual statistical validity of the sample as drawn and conducted.” As the above quoted authority make clear, the test is whether the methodology is statistically valid. The provider whose claims are being audited is protected from a degree of imprecision or uncertainty by the provision that limits overpayments to the lower level of a specified confidence interval unless high precision results from the sampling.

Referral Document

Appeals Council Decision

 
1-868363006 - Friday, February 22, 2013
Rationale for the Referral: An ALJ must make a substantive coverage determination prior to any liability or waiver analysis.

Referral Document

Appeals Council Decision
 
1-759747445 - Thursday, October 27, 2011

Rationale for the Referral: The ALJ determined correctly that the Appellant should have billed for thermal intradiscal procedures using CPT code 64999 (unlisted procedure, nervous system). The ALJ did not deny the claims based on a determination they were not reasonable and necessary under § 1862(a)(1)(A) of the Social Security Act (the Act); rather he found the services were coded incorrectly. Thus, the waiver of liability provision of § 1879 of the Act does not apply to waive the Appellant’s liability for any overpayment. Additionally, the Appellant is not entitled to a waiver of recoupment under § 1870(b) of the Act because, when faced with multiple coding options, it failed to request clarification from the Medicare contractor.

Referral Document

Appeals Council Decision

 
1-690694743 - Friday, October 7, 2011

Rationale for the Referral: 1. The ALJ’s decision must be based on evidence offered at the hearing or otherwise admitted into the record. 42 C.F.R. § 405.1046(a). 2. Appellant’s arguments that the sample did not accurately represent the universe and that the PSC did not “look for underpayments” are not grounds for invalidating the sampling and extrapolation.

Referral Document

Appeals Council Decision

 
  
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