Overpayment Procedures

8.2 – Overpayment Procedures (Rev. 11032; Issued: 09-30-21; Effective: 10-12-21; Implementation: 11-10-21) This section applies to Medicare Administrative Contractors (MACs) and Unified Program Integrity Contractors (UPICs). The UPIC shall refer all identified overpayments to the MAC who shall send the demand letter and recoup the overpayment. Contractors should initiate recovery of overpayments whenever it is determined that Medicare has erroneously paid. In any case involving an overpayment, even where there is a strong likelihood of fraud, contractors shall request recovery of the overpayment. The UPIC shall refer such overpayments to the MAC only after the investigation has been vetted with CMS (see Pub. 100-08, chapter 4, section 4.6). In addition, if a UPIC is making a referral to law enforcement, it shall refrain from referring the overpayment determination to the MAC during specified times noted in Pub. 100-08, chapter 4, section 4.9.4. If a large number of claims are involved, contractors consider using statistical sampling for overpayment estimation to calculate the amount of the overpayment. (See section 8.4 of this chapter.) Contractors have the option to request the periodic production of records or supporting documentation for a limited sample of submitted claims from providers or suppliers to which amounts were previously overpaid to ensure that the practice leading to the overpayment is not continuing. The MAC may take any appropriate remedial action described in this chapter if a provider or supplier continues to have a high level of payment error. Offer the provider a consent settlement based on the potential projected overpayment amount.