What is a Medicare recoupment?

A Medicare recoupment is a process under which Medicare seeks to recover payments that were made to a healthcare provider or beneficiary in error. A recoupment usually happens after a post-payment audit when Medicare determines that a provider was overpaid because the claims were submitted incorrectly, fraudulently, or the services provided were determined to be medically unnecessary.

I. Common Scenarios That Trigger Recoupment Audits:

Statistics: The most common scenario is an allegation by the Medicare contractor that there is "credible evidence regarding data analysis findings."

Overpayments: Medicare may discover that they paid more than they should have for a particular claim due to provider billing errors or a provider's alleged misinterpretation of Medicare rules.

Medical Necessity: Medicare may deny payment or seek recoupment if they determine that the services provided were not medically necessary. Services that were medically unnecessary is a common Medicare finding, especially for home health agencies and when billing uncommon procedure codes.

Fraudulent Billing: If Medicare finds evidence of fraud, billing for services not provided, or upcoding, for example, they will seek to recover the funds paid. However, a civil or criminal prosecution is more likely than a recoupment under this scenario.

An Audit: An internal Medicare audit can trigger a recoupment if Medicare determines that the claims did not meet Medicare policy manual guidance or were not compliant with Medicare rules.

II. The Recoupment Process:

Notification: The provider will receive a notice from Medicare or one of its contractors indicating that the provider was overpaid.

Recoupment of Funds: Medicare can initiate recoupment by deducting the amount owed from future Medicare payments to the provider.

Appeals Process: Providers have the right to appeal the recoupment decision. The assistance of an experienced recoupment attorney such as Mr. Rosenblat can substantially increase the likelihood that the recoupment will be reversed or lessened based on the facts and the law.

Timeframes: There are time limitations on filing the various levels of appeal. Healthcare providers should work with an experienced attorney to navigate the recoupment process. Attorney Mike Rosenblat and Rosenblat Law have successfully represented providers in Medicare, Medicaid, and private insurance audits and recoupments.

If you're looking for a lawyer to handle a Medicare recoupment case, look no further than Rosenblat Law, a law firm in Northbrook, Illinois. Medicare recoupments generally involve situations where Medicare has determined that a provider has been overpaid for services or claims, and they seek to recoup those funds.

III. What to look for when hiring a Medicare Recoupment Defense lawyer:

Specialization: Look for a lawyer concentrating on healthcare law, particularly in Medicare and Medicaid issues. These attorneys will deeply understand federal and state regulations and can offer targeted advice. Attorney Rosenblat has extensive experience in recoupment and payment issues, having worked for the Medicaid Fraud Control Unit.

Experience with Medicare Recoupment: Ensure the lawyer has specific experience with Medicare recoupment cases. Attorney Rosenblat has extensive expertise in understanding how Medicare audits work, how the recoupment process unfolds, and how to challenge or negotiate repayment requests. Attorney Rosenblat has saved his clients over $1 million.

Familiarity with Administrative Appeals: You may need to challenge the recoupment through an administrative appeals process. Attorney Rosenblat is experienced in administrative appeals to the OMHA, Office of Medicare Hearings and Appeals, and never lost a case presented to OMHA.

Negotiation Skills: If you want to settle or reduce the recoupment amount, a lawyer with strong negotiation skills will be key. Attorney Rosenblat's professional and persuasive writing skills have resolved many recoupments at the reconsideration or redetermination levels.

Contact Attorney Michael Rosenblat for more information.