Determining Overpayments and Underpayments

3.6.1 - Determining Overpayments and Underpayments (Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20) This section applies to MACs, and UPICs. It does not apply to CERT or Recovery Auditors. A. General The results of the re-adjudication are used to determine the overpayment or underpayment amount for each claim. Re-adjudicating claims may not result in a payment correction. Where statistical sampling for overpayment estimation is used, refer to instructions in the PIM chapter 8, §8.4 and to Exhibits 9, 10, 11 and 12 for projection methodologies based on FFS claims. For claims paid under PPS rules, MACs and UPICs shall develop projection methodologies in conjunction with their statisticians that are consistent with the requirements found in PIM chapter 8, §8.4. MACs and UPICs shall net out the dollar amount of services underpaid during the cost accounting period, meaning that amounts owed to providers are balanced against amounts owed from providers. Amounts of the following overpayments are to be included in each provider's or supplier’s estimate for the reviewed sample: • According to the provisions of §1879 of the Act, the provider or supplier is liable for the overpayment of initially paid claims that were later denied on re- adjudication if : (1) The basis for denial is by reason of §1862(a) (l) or (9) of the Act (2) The provider or supplier knew or could reasonably have been expected to know that the items or services were excluded from coverage, and • For denials of non-assigned claims make a§1842(l) determination on denials for §1862(a)(1) • The provider or supplier was not without fault for the overpayment as defined in §1870 of the Act. For appeal purposes, overpayment estimations applicable under §1879 of the Act will be identified separately from denials in which §1879 of the Act does not apply. Where both types of denials occur in the sample, MACs and UPICs calculate and document separate under/overpayments for each type of denial. For recovery purposes, however, both denial results are combined.