Conduct of Expanded Review Based on Statistical Sampling

8.2.3.2 – Conduct of Expanded Review Based on Statistical Sampling for Overpayment Estimation and Recoupment of Projected Overpayment by Contractors (Rev. 10228; Issued: 07-27-20; Effective: 08-27-20; Implementation: 08-27-20) The MACs shall perform the actual recoupment identified by the UPICs. When a UPIC or medical review audit determines an extrapolated overpayment the sample claims reviewed are adjusted for denial. For history purposes, contractors shall deny the sample claims individually in the shared system and shall suppress the sample claims from going to HIGLAS. Once the entire extrapolated amount is identified, contractors shall create one large account receivable (AR) for the extrapolated amount (including the adjusted sample claim amounts) to demand and recoup. A. If an expanded review of claims is conducted, contractors shall follow the sampling instructions found in section 8.4 of this chapter, obtain and review claims and medical records, and document for each claim reviewed: ο The amount of the original claim; ο The allowed amount; ο The rationale for denial; o The §1879 determination for each assigned claim in the sample denied because the service was not medically reasonable and necessary (or the §1842(1) provider/supplier refund determination on non-assigned provider/supplier claims denied on the basis of §1862(a)(1)(A)) (refer to Exhibit 14.1 of this manual); ο The §1870 determination for the provider/supplier for each overpaid assigned claim in the sample (refer to Exhibit 14.2 of this manual); and ο The amount of overpayment (after allowance for deductible and coinsurance). B. Contractors calculate the projected overpayment by extrapolating from the actual overpayment to the universe that excludes those claims determined that the provider/supplier did not have knowledge that the service was not medically necessary; C. Notify the provider/supplier of the preliminary projected overpayment findings and review findings; D. If the provider/supplier submits additional documentation, review the material and adjust the preliminary projected overpayment findings, accordingly; E. Calculate the final overpayment; and F. Refer to the overpayment recoupment staff.