Sampling Methodology Overturned

8.4.9.1 - Sampling Methodology Overturned (Rev. 12127; Issued: 07-21-23; Effective: 08-21-23; Implementation: 08-21-23) If the decision issued on appeal contains a finding that the sampling methodology was invalid, there are several options for revising the estimated overpayment based upon the appellate decision: A. If the decision issued on appeal permits correction of errors in the sampling methodology, the contractor shall revise the overpayment determination after making the corrections. The contractor shall consult with its BFL, with a copy to the COR, to confirm that this course of action is consistent with the decision of the MAC, Qualified Independent Contractor (QIC), Administrative Law Judge (ALJ), Medicare Appeals Council (the Council) within the Departmental Appeals Board (DAB), or Federal District Court. B. The contractor may elect to recover the actual overpayments related to the sampled claims and then initiate a new review of the provider or supplier. If the actual overpayments related to the sampling units in the original review have been recovered, these individual sampling units shall be eliminated from the sampling frame used for any new review. The contractor shall consult with its BFL, with a copy to the COR, to confirm that this course of action is consistent with the decision of the MAC, QIC, ALJ, the Council or Federal District Court. C. The contractor may conduct a new review (using a new, valid methodology) for the same time period covered by the previous review. If this option is chosen, the contractor shall not recover the actual overpayments on any of the sample claims found to be in error in the original sample. Before employing this option, the contractor shall consult with its BFL, with a copy to the COR, to verify that this course of action is consistent with the decision of the MAC, QIC, ALJ, Council, or the Federal District Court.