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ProviderLAW Study on Recoupment
Research Sponsored by dK Coding & Compliance, Inc.
"Recoupment" by Carriers is on the Rise. What Are the Major Limitations Which Apply to Carriers Who Wish to Recoup (i.e., Recover) Benefits Previously Paid to Healthcare Providers / Suppliers?

A copy of this study
can be accessed though ProviderLAW.com
www.providerlaw.com > Public

First Published: 12-21-05

    

Last Revised: 12-22-05

    

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Drafted by: ProviderLAW
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  1. Who Should Read This Study?

This study is specifically designed for healthcare providers, billing companies, management consultants, healthcare attorneys, and professional associations (national / state / regional). Its purpose is to help empower healthcare providers through (1) an examination of the major limitations on recoupment by insurance payers, and (2) the development of resources which healthcare practices and solution providers can use, both at the practice level and network level, to prevent and resolve recoupment.

If you are a provider, and you become the subject of a post-payment review and recoupment request, we certainly encourage you to share a copy of this study with your attorney.

We also invite any comments which you, the reader, may have regarding this initial study.

  1. Introduction – The Growing Trend of Recoupment

Increasingly, we at ProviderLAW are hearing anecdotal stories of insurance payers performing "post-payment reviews" and requesting refunds – not just in the amount of tens or hundreds of dollars, but rather in the amount of thousands, tens of thousands, and even hundreds of thousands of dollars – from healthcare providers or suppliers for care previously rendered and paid for.

Providers are told that if they fail to respond to the requests for refunds within the time allotted, the carriers will begin deducting the money which they claim they are owed out of future payments due to the providers.

This form of recovery is often referred to as "recoupment," "offset," or "setoff."

The payers' rationales for requesting refunds range anywhere from "insufficient documentation" on the one end of the spectrum to allegations of "fraud" on the other end.

The issue of recoupment is exacerbated by the fact that in some cases, the payers will not disclose the total amount they believe they are owed. In some cases, the payers will not disclose the patient accounts which they claim were overpaid. In some cases, the payers will not provide a rationale for their claim that they are owed money. In some cases, the carriers fail to provide any prior notice to the providers that they intend to deduct payments, but simply begin recouping. In some cases, the carriers base their overpayment calculations on care provided years previously. In most cases, the patients and care from which the payers begin to deduct payment have nothing at all to do with the patients or care which are now the subject of the carriers' review.

What's more, the carriers will often calculate the total amount due through a process referred to as "extrapolation" – the process of using an audit sample to calculate the total amount due for an entire population of previously-submitted claims.

In one recent case, an ERISA health benefits plan which claimed it was owed $500,000 back from a healthcare provider, simply issued a claims "block," – i.e., refused to process any more claims from the provider until the provider either paid or settled with the payer. The trial court in that case issued an injunction against the health benefits plan based on legal research and theories provided to the plaintiff's attorneys by ProviderLAW.

Indicative of the increase in recoupment activity is the fact that in January, 2005, the American Medical Association formally published a brochure, "How to Prepare for a Health Plan Retrospective Audit." This brochure not only referenced the development of an online complaint form which providers can use to report "unfair health insurer and payer business practices," it also referenced a formal AMA policy to "...oppose arbitrary, erratic, or inappropriate components of post-payment review and recoupment...." (See AMA Policy, "Medical Office Screens," H-335.981).

Also indicative of the increase in recoupment activity, as well as its immense reach, is the fact that in June of 2005, the Department of Health and Human Services, Office of Inspector General (OIG) issued a report entitled, "Chiropractic Services in the Medicare Program: Payment Vulnerability Analysis." In this report, the OIG claimed that approximately 67% of chiropractic claims in 2001 were paid in error resulting in $285 million in improper payments. Subsequently, the OIG recommended that carriers should begin to "obtain and review the records of [chiropractors] ... in order to identify and collect overpayments" (p. 16, emphasis added). The OIG mandated that "[w]hen conducting reviews of individual providers, it is imperative that reviewers collect the entire records associated with services selected as part of a service-specific review" (p. 16, emphasis added). For sample audit letters, see the September 2005 CERT Newsletter, p. 8-11 (Note: The use of "CERT" here is a reference to CMS' post-payment review program officially referred to as the CMS "Comprehensive Error Rate Testing" (CERT) program).

Significantly, the OIG acknowledged at the end of the report that chiropractic services allowed by the Medicare program in 2001 only amounted to 0.26 percent of the total amount of fee-for-service claims allowed by the Medicare program during that year. Nevertheless, signaling a possible increase in post-payment reviews in NON-Medicare settings, the OIG made a final recommendation to CMS. In light of CMS' limited resources, the OIG recommended that CMS consider conducting error-testing studies of the chiropractic profession "outside the scope of the CERT program...." (emphasis added).

In the last analysis, few may dispute that recoupment takes the challenges associated with claims denials to an entirely new level. Now, instead of just denying claims, carriers are increasingly beginning to reach back in time and to reclaim monies previously paid to healthcare providers.

Accordingly, this study looks at the major limitations which apply to carriers who wish to recoup money from healthcare providers.

  1. Quick Overview of This Study

At this juncture, this study focuses on law applicable to Medicare Part B carriers. We focus on Medicare primarily because recoupment law appears to be most defined in this arena, relatively speaking. As time progresses, this study will be broadened to include other areas of insurance as well. For more information regarding recoupment in ERISA health benefit plan settings, see "ProviderLAW Advisory – Part II: ...Can Carriers Really Recoup From You? Without Notice? In Any Amount They Please? What's Next?" (First Published: 09-22-05).

Under Medicare law, there appear to be at least four major limitations that apply to carriers who wish to recoup. Each of these major limitations are explained further in this study. Again, if you are a provider, and you become the subject of a post-payment review and recoupment request, we encourage you to share a copy of this study with your attorney.

The major limitations include the following:

  1. Major Limitation #1 – Providers Can Prevent Recoupment if They Can Show (1) That They Were "Without Fault" and (2) That It Would Be "Against Equity and Good Conscience" as These Phrases Are Defined by the Regulations.
  2. Major Limitation #2 – If the Services (From Which the Carrier is Attempting to Recoup) Are Not Part of the "Same Transaction" as the Services Which the Carrier Claims Were Previously Overpaid, Then Recoupment is Not Available as a Remedy Under the Regulations.
  3. Major Limitation #3 – According to the Health and Human Services, Medicare Usually Does Not Impose 100% Recoupment. Medicare is Also Amenable to Creating Payment Arrangements of Three Years or More in Duration.
  4. Major Limitation #4 – Medicare Cannot Necessarily Extend Its Recoupment Efforts Back Three (3) Years.

It should be noted that these are not the only limitations which apply. Other limitations are contained and set forth in the Code of Federal Regulations (CFR). Providers who are interested in reviewing the Code of Federal Regulations, and learning more about additional limitations, are encouraged to use the research tool which we have developed and placed in Appendix A of this study. The research tool will help you more quickly and easily review applicable CFR provisions.

Moreover, as time progresses, we will be updating this study with additional content and discussion.

Important note – each year, the federal government updates its online CFR database. Throughout this study, links to specific sections of the Code of Federal Regulations are to the 2005 publication of those regulations. If you wish to access the most current version of the regulations, as well as past versions, we recommend that you consider creating a bookmark to the General Table of Contents for the Code of Federal Regulations.

  1. Under Medicare Part B, What Are Some of the Major Limitations on Recoupment?
  1. Introduction – A Newsletter Article Published by the AAPS in 1994

In its January 1994 newsletter, the American Association of Physicians and Surgeons provided the following advice to healthcare providers regarding Medicare recoupment (see excerpt below). After reviewing the controlling law on point, we concluded that the AAPS article continues to provide a useful overview and introduction to recoupment by Medicare.

We will attempt to explain this AAPS excerpt in subsequent sections of this study.

In its newsletter, the AAPS wrote (links and notes added):

"First, don't agree to anything with the carrier either orally or in writing. At worst, such an agreement can result in a total waiver of physicians' rights to keep the alleged overpayments. At best, it can amount to an admission of liability for an alleged overpayment, which can be used against the physician in administrative and judicial proceedings to contest the contemplated recoupment. [Note: on the issue of agreements, see 42 CFR 401.607(c)].

"Second, the physician should immediately retain competent counsel as soon as he receives notice of the recoupment. Counsel should notify the carrier in a formal legal document that the physician objects to the recoupment, that the physician is totally without fault, that the recoupment is contrary to equity and good conscience and constitutes the equivalent of retroactive rulemaking, violating the physician's rights under the Medicare Act, [Sections] 1395 et seq., and the US Constitution. The document should demand a formal administrative hearing to contest the recoupment before an offset begins or alternately, without waiving the right to a pre-recoupment hearing, a hearing as soon as possible. [Note: on the meaning of 'equity and good conscience,' see 20 CFR 404.509 and 42 CFR 405.355(b)]

"Under 42 U.S.C. [Sections] 1395gg, [CMS] may not recoup an alleged overpayment if the physician is without fault and the recoupment would be against equity and good conscience. Additionally, the physician has the right to a hearing and appeal rights."

Citation: "Pennsylvania Medicare Recoupment May Foreshadow Future Recoupments by Other Medicare Carriers: Physicians Must Know Their Legal Rights," American Association of Physicians and Surgeons (AAPS), AAPS Newsletter, January 1994, paragraphs 7-9.

Our study will now attempt to explain some of the basic concepts contained in the excerpt above.

  1. LIMITATION #1 – Arguably, Providers Can Prevent Recoupment if They Can Show (1) That They Were "Without Fault" and (2) That It Would Be "Against Equity and Good Conscience" as These Phrases Are Defined by the Regulations.

42 CFR 405.355 is entitled, "Waiver of adjustment or recovery." Arguably, under this provision, providers who satisfy a two-prong test can prevent recoupment by Medicare carriers. The first prong requires the provider to show that the clinic was "without fault" with respect to the overpayment. The second prong requires the provider to show either that recovery by CMS would "defeat the purpose of title II or title XVIII of the Act," or would be "against equity and good conscience" (see, e.g., 20 CFR 404.509 and 42 CFR 405.355(b)).

Notably, 20 CFR 404.509 suggests that it would be against "equity and good conscience" if the provider "changed his or her position for the worse ... or relinquished a valuable right ... because of reliance upon a notice that a payment would be made or because of the overpayment itself...."

With respect to the issue of "fault," 20 CFR 404.507 provides as follows (emphasis added):

"Although the Administration may have been at fault in making the overpayment, that fact does not relieve the overpaid individual or any other individual from whom the Administration seeks to recover the overpayment from liability for repayment if such individual is not without fault.... What constitutes fault ... on the part of the overpaid individual or on the part of any other individual from whom the Administration seeks to recover the overpayment depends upon whether the facts show that the incorrect payment to the individual or to a provider of services or other person, or an incorrect payment made under section 1814(e) of the Act, resulted from:

(a) An incorrect statement made by the individual which he knew or should have known to be incorrect; or

(b) Failure to furnish information which he knew or should have known to be material; or

(c) With respect to the overpaid individual only, acceptance of a payment which he either knew or could have been expected to know was incorrect."

20 CFR 404.507 (emphasis added)

Of course, reasonable people may differ as to the meaning of the phrase, "knew or could have been expected to know."

By way of example, consider Tsoutsouris v. Shalala, 977 F.Supp. 899 (N.D.In., 1997). In this case, an Indiana federal district court held that a provider's documentation in a series of patient cases deviated from Medicare Carrier Manual documentation guidelines. Based on this finding, the court held that the provider "knew or could have been expected to know" that payment was incorrect, and therefore that the provider should not prevail in the pre-recoupment hearing. The court held that the provider's documentation was insufficient because it was "largely illegible," contained frequent use of "vague" phrases including, "as above," and failed to note the extent of the initial condition as well as the progress of its healing.

Indeed, ample evidence indicates that the rationale, "insufficient documentation," will represent the cornerstone of most recoupment efforts by insurance payers. For instance, earlier in this study, we cited to a report issued by the OIG, "Chiropractic Services in the Medicare Program: Payment Vulnerability Analysis." In this report, the OIG specifically tells Medicare carriers, when conducting post-payment reviews, to look for compliance with documentation standards published in the Medicare Carriers Manual. The September 2005 issue of the CERT Newsletter (p. 2) gets even more specific. In extended care situations (such as chiropractic), the Newsletter indicates that CMS reviewers will be examining, among other things, whether the documentation includes a "plan of care" – i.e., a treatment plan.

On a final note, bear in mind that despite the above provision on fault – 20 CFR 404.507 – and despite the opinion of the AAPS, it is possible that not all courts will necessarily agree that providers are entitled to a pre-recoupment administrative hearing. This topic will be examined further in upcoming versions of this study.

  1. LIMITATION #2 – If the Services (From Which the Carrier is Attempting to Recoup) Are Not Part of the "Same Transaction" as the Services Which the Carrier Claims Were Previously Overpaid, Then Recoupment is Not Available as a Remedy Under the Regulations.

Under 42 CFR Section 405.370, recoupment is defined as "the recovery by Medicare of any outstanding Medicare debt by reducing present or future Medicare payments and applying the amount withheld to the indebtedness." Arguably, however, this definition fails to identify a long-established limitation inherent to recoupment – a limitation recognized in other contexts such as bankruptcy law. The limitation is this: If the Carrier wishes to recoup, the services (from which the carrier is attempting to recoup) must be part of the "same transaction" as the services which the carrier now claims were overpaid.

To understand this limitation, consider the following case: In re University Medical Center, 973 F.2d 1065 (3rd Cir., 1992). In this case, the Third Circuit Court of Appeals held that while Medicare was claiming that it was "recouping" from a healthcare provider, since the services from which it was deducting funds were not part of the "same transaction" as the services which were overpaid, the carrier's collection activity fell outside the definition of recoupment.

In holding that the carrier's collection activity fell outside the definition of recoupment, the Court of Appeals wrote:

"'The Provider Agreement is a unique type of contract. It does not provide for a defined transaction or even a series of transactions. It simply establishes a relationship between the parties.' ...The typical situation in which equitable recoupment can be invoked involves ... debt arising out of a transaction for the same goods or services. To conclude that these claims arose from the same transaction for the purposes of equitable recoupment would be to contort that doctrine beyond any justification for its creation...."

In re University Medical Center, 973 F.2d 1065, 1081-1082 (emphasis added).

Bear in mind that not all courts may agree with the Third Circuit Court of Appeal's conclusion or reasoning. As time progresses, this study will continue to examine the issue – to what extent can certain services of a provider be deemed to be part of the "same transaction" as other services rendered by that provider?

Nevertheless, the upshot of the discussion is still the same – if the services which the carrier seeks to recoup FROM are not part of the "same transaction" as the services which the carrier seeks to recoup FOR, then the collection activity falls outside the definition of recoupment.

  1. LIMITATION #3 – According to the Health and Human Services, Medicare Usually Does Not Impose 100% Recoupment. Medicare is Also Amenable to Creating Payment Arrangements of Three Years or More in Duration.

1n 1996, the HHS proposed a round of changes to the Medicare recoupment rules cited above. In the process, numerous healthcare organizations and entities submitted comments to the HHS, expressing concern regarding the "devastating" effect that such rules could have on healthcare providers.

The HHS summarized the comments as follows:

"...Several commenters expressed concern that the proposed changes concerning suspension of Medicare payments in cases of overpayments would allow an intermediary or carrier to withhold all payment to a provider or supplier without notification until an overpayment was recouped and that this could have a devastating effect on the cash flow of providers and suppliers, possibly even causing bankruptcies. ...Since immediate suspension of payments could cause great hardship to many Medicare providers and suppliers, one commenter believed it only fair to continue the requirement of a separate determination that suspension is needed to protect the program from financial loss."

61 Federal Register 63740, pp. 63741-63742

In its response to these comments, the HHS declared that if a provider responds to a recoupment notice, "Medicare usually does not impose 100 percent recoupment in absence of a basis for doing so." Specifically, the HHS wrote (emphasis added):

"Once a determination is made, any overpayments will be recouped or offset, first from suspended funds, then from any other monies owed the debtor in accordance with usual Medicare program rules. (See, for example, [42 CFR] 401.607(a)). Note that, in contrast to the decision to suspend payment, an overpayment determination is an initial determination, subject to appeal, but that appeals do not delay recoupment. Also note that, as defined in this final rule at §405.370, recoupment may constitute 100 percent of any monies due if the debt to Medicare is equal to or greater than the amounts payable. Nonetheless, for the very reasons raised by the commenters, Medicare usually does not impose 100 percent recoupment in the absence of a basis for doing so, such as the debtor's failure to respond to a demand letter."

61 Federal Register 63740, p. 63743 (emphasis added)

Note how in its response, the HHS cited another rule governing recoupment – 42 CFR 401.607. This rule currently provides in relevant part (emphasis added):

"42 CFR 401.607 Claims collection.

(a) General policy. CMS recovers amounts of claims due from debtors, including interest where appropriate, by--

(1) Direct collections in lump sums or in installments; or

(2) Offsets against monies owed to the debtor by the Federal government where possible.

(b) Collection in lump sums. Whenever possible, CMS attempts to collect claims in full in one lump sum. However, if CMS determines that a debtor is unable to pay the claim in one lump sum, CMS may instead enter into an agreement to accept regular installment payments.

(c) Collection in installments. Generally, CMS requires that all claims to be satisfied by installment payments must be liquidated in three years or less. If unusual circumstances exist, such as the possibility of debtor insolvency, an installment agreement that extends beyond three years may be approved.

(1) Debtor request. If a debtor desires to repay a claim in installments, the debtor must submit--

(i) A request to CMS; and

(ii) Any information required by CMS to make a decision regarding the request.

(2) CMS decision. CMS will determine the number, amount and frequency of installment payments based on the information submitted by the debtor and on other factors such as--

(i) Total amount of the claim;

(ii) Debtor's ability to pay; and

(iii) Cost to CMS of administering an installment agreement."

42 CFR 401.607 (emphasis added)

Based on the above provisions, it appears that Medicare will generally allow up to three years to pay back the debt which otherwise it would recoup immediately from the provider. In the event that recoupment could lead to insolvency, Medicare is authorized to grant an even longer payment period.

  1. LIMITATION #4 – Medicare Cannot Necessarily Extend Its Recoupment Efforts Back Three (3) Years.

At least one other limitation on recoupment needs to be carefully examined. In this case, the limitation is outlined in 42 CFR 405.355(b). Section 405.355(b) provides in relevant part (emphasis added):

"(b) Adjustment or recovery of an incorrect payment ... shall be deemed to be against equity and good conscience if the determination that such payment was incorrect was made subsequent to the third year following the year in which notice of such payment was sent to such individual."

42 CFR 405.355(b) (emphasis added)

It should be noted that this provision does not say that Medicare can necessarily go back three (3) years in its recoupment efforts. What it does appear to say is that recoupment efforts which extend back more than three years are necessarily against equity and good conscience. Other factors may support a finding that a recoupment effort extending back, say, more than six (6) months in any given case, could potentially be found to be against equity and good conscience. See, e.g., 20 CFR 404.509.

On this note, consider an event which occurred after the OIG issued its report, "Chiropractic Services in the Medicare Program: Payment Vulnerability Analysis." Recall that in the report, the OIG specifically mandated that "[w]hen conducting reviews of individual providers, it is imperative that reviewers collect the entire records associated with services selected as part of a service-specific review" (p. 16, emphasis added). Soon thereafter, the following announcement was inserted in the September 2005 issue of the CERT Newsletter (links added):

"Recently, the CERT Contractors were instructed by CMS to suspend requesting medical records from chiropractors. During this period, administrators at CMS evaluated an OIG recommendation to request records/documentation for services provided to patients six (6) months prior to the date of service for the claim under review.

"CMS is in agreement with the OIG recommendation and has directed the CERT Contractors to request records/documentation for the period covering 6 months prior to the date of service associated with the same condition under claim review. This documentation should include a plan of care to support chiropractic services rendered for the course of treatment.

"To that end, the CERT Contractors will send providers of chiropractic services a request letter with specific instructions to provide records/documentation that cover the period for the preceding six (6) months prior to the date of service for the sampled claim.... Samples of the letters can be seen as attachments to this issue of the CERT Newsletter."

CERT Newsletter, September, 2005 p.2

Time will tell whether Medicare carriers, based on six months of records, will request refunds for services dating back six months, or whether they will attempt to "extrapolate" from the six month sample, and request refunds dating back for a longer period of time.

  1. Networking and Communication Will Play a Key Role in Helping Providers to Prevent and Resolve Recoupment Issues.

Before concluding this study, we wish to emphasize an important anecdotal story which was recounted in the January 2004 issue of the American Association of Physicians and Surgeons' Newsletter – a story which we have not previously discussed. We believe that this account illustrates the potential role that networking and communication can, and will, play in helping providers to prevent and resolve recoupment issues.

In its January 1994 issue, the AAPS provided the following recoupment account:

"Pennsylvania Blue Shield, the Medicare carrier that administers Part B in Pennsylvania, New Jersey, Delaware, and the District of Columbia, is attempting to recoup about $12.6 million in alleged Medicare overpayments from 3,000 physicians and clinical laboratories. According to the Bureau of National Affairs (4 Medicare Report 1431, BNA, 11/19/93), Blue Shield conducted an internal audit of its records, uncovering a 'clerical error' that resulted in 'paying more for certain panels of laboratory tests than it would have paid if the component tests were billed separately.'

"According to David Sayen, a spokesman in the Region III Office of [CMS] in Philadelphia, new Medicare fee schedules adopted in 1993 eliminated the potential for such error, but during the preceding three years, the fact that fees were capped for individual tests but not for panels of tests created the opportunity for such a carrier mistake.

"After discovering the alleged error on its part, Pennsylvania Blue Shield sent letters to physicians and laboratories, giving them 15 days to object to having future Medicare payments offset by the carrier to make up for the alleged overpayments. Blue Shield also notified physicians and laboratories that they would have a 'grace period' of 30 days before recoupment would be initiated, after which interest would begin to accrue on the alleged overpayment at the rate of 13.6%.

"According to BNA, Pennsylvania physicians and laboratories strongly objected to the recoupment on the grounds that they were not at fault for the carrier's alleged error and were being penalized unfairly.

"Due to these objections, Pennsylvania Blue Shield put its recoupment plans on hold, 'pending the outcome of discussions with [CMS].' According to the spokesman for the carrier, the decision as to whether to proceed with the recoupment rests entirely with [CMS]."

Citation: "Pennsylvania Medicare Recoupment May Foreshadow Future Recoupments by Other Medicare Carriers: Physicians Must Know Their Legal Rights," American Association of Physicians and Surgeons (AAPS), AAPS Newsletter, January 1994, paragraphs 1-5.

Can something be done about the way in which carriers attempt to recoup? Judging by the above story, the answer would appear to be "absolutely."

Information will certainly play a key role in helping providers to address the challenges of unrestricted recoupment by insurance carriers. But something more is needed as well. We believe the above story contains an important lesson on this very point.

  1. Conclusion

This study is specifically designed for healthcare providers, billing companies, management consultants, healthcare attorneys, and professional associations (national / state / regional). Its purpose is to help empower healthcare providers through (1) an examination of the major limitations on recoupment by insurance payers, and (2) the development of resources which healthcare practices and solution providers can use, both at the practice level and network level, to prevent and resolve recoupment.

This study focuses on law applicable to Medicare Part B carriers. We focus on Medicare primarily because recoupment law appears to be most defined in this arena, relatively speaking. As time progresses, this study will be broadened to include other areas of insurance as well.

Under Medicare law, there appear to be at least four major limitations that apply to carriers who wish to recoup. The major limitations include the following:

  1. Major Limitation #1 – Providers Can Prevent Recoupment if They Can Show (1) That They Were "Without Fault" and (2) That It Would Be "Against Equity and Good Conscience" as These Phrases Are Defined by the Regulations.
  2. Major Limitation #2 – If the Services (From Which the Carrier is Attempting to Recoup) Are Not Part of the "Same Transaction" as the Services Which the Carrier Claims Were Previously Overpaid, Then Recoupment is Not Available as a Remedy Under the Regulations.
  3. Major Limitation #3 – According to the Health and Human Services, Medicare Usually Does Not Impose 100% Recoupment. Medicare is Also Amenable to Creating Payment Arrangements of Three Years or More in Duration.
  4. Major Limitation #4 – Medicare Cannot Necessarily Extend Its Recoupment Efforts Back Three (3) Years.

It should be noted that these are not the only limitations which apply. Other limitations are contained and set forth in the Code of Federal Regulations (CFR). Providers who are interested in reviewing the Code of Federal Regulations, and learning more about additional limitations, are encouraged to use the research tool which we have developed and placed in Appendix A of this study. The research tool will help you more quickly and easily review applicable CFR provisions.

Moreover, as time progresses, we will be updating this study with additional content and discussion.

If you are a provider, and you become the subject of a post-payment review and recoupment request, we encourage you to share a copy of this study with your attorney.

We also invite any comments which you, the reader, may have regarding this initial study.

Appendix A

A Tool For Enabling Providers
to Quickly Review Medicare Law (2005 Version)

This section provides a quick overview of Medicare provisions relating recoupment. It also provides a tool for more easily browsing through the provisions which apply and becoming more familiar with the source law itself. We are providing this tool because there may be a number of limitations which apply to recoupment which are not discussed or highlighted in this study. We encourage you, the reader, to review these provisions and to become more familiar with them.

As you review the table below, pay particular attention to the topics which appear in bold. Again, bear in mind that the links listed below will enable you to view the 2005 version of the CFR section in question.

405.350 Individual's liability for payments made to providers and other persons for items and services furnished the individual.
405.351 Incorrect payments for which the individual is not liable.
405.352 Adjustment of title XVIII incorrect payments.
405.353 Certification of amount that will be adjusted against individual title II or railroad retirement benefits.
405.354 Procedures for adjustment or recovery--title II beneficiary.
405.355 Waiver of adjustment or recovery.
405.356 Principles applied in waiver of adjustment or recovery.
405.357 Notice of right to waiver consideration.
405.358 When waiver of adjustment or recovery may be applied.
405.359 Liability of certifying or disbursing officer.
405.370 Definitions [of Offset, Recoupment, and Suspension]
405.371 Suspension, offset, and recoupment of Medicare payments to providers and suppliers of services.
405.372 Proceeding for suspension of payment.
405.373 Proceeding for offset or recoupment.
405.374 Opportunity for rebuttal.
405.375 Time limits for, and notification of, administrative determination after receipt of rebuttal statement.
405.376 Suspension and termination of collection action and compromise of claims for overpayment.
405.377 Withholding Medicare payments to recover Medicaid overpayments.
405.378 Interest charges on overpayment and underpayments to providers, suppliers, and other entities.
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