Recovery From Provider or Supplier

8.4.7.1 - Recovery From Provider or Supplier (Rev. 12127; Issued: 07-21-23; Effective: 08-21-23; Implementation: 08-21-23) Once an overpayment has been determined to exist, the UPIC shall provide its BFL, with a copy to the COR, a summary of the investigation, any prior history (if applicable), the medical review results (including denial reasons), and the extrapolated overpayment amount in a format agreed upon by CPI for all extrapolation requests not associated with a Payment Suspension. If the CPI agree that an extrapolated overpayment is appropriate, the UPIC shall include the case on the next case coordination meeting agenda for discussion and final approval. During the case coordination meeting, the UPIC may receive additional guidance from CMS related to subsequent actions associated with the investigations. If the UPIC has subsequent questions following the case coordination meeting, the UPIC shall coordinate with its COR and/or BFL, as needed. The contractor shall include in the overpayment demand letter information about the review and statistical sampling methodology that was followed. Only MACs shall issue demand letters and recoup the overpayment. In the Final Review Results sent to the provider/supplier, the contractor shall include information about the review and statistical sampling methodology that was utilized for estimation. The explanation of the sampling methodology that was followed shall include all of the following: • A description of the universe, the sampling frame, and the sampling methodology, • A definition of the sampling unit, • The sample selection procedure followed, and the numbers and definitions of the strata and size of the sample, including allocations, if stratified, • The time period under review, • The overpayment estimation, the overpayment estimation methodology, and the calculated sampling error; and • The amount of the actual overpayment/underpayment from each of the claims reviewed. The contractor shall also include a list of any problems/issues identified during the review and any recommended corrective actions.