Appeal

[dfranklin]

Can we file an appeal if we received a letter from Medicare asking for a repayment for overpayment claims?

We received a letter stating the reason for overpayment was the claim was submitted with incorrect information concerning the number of services or entry of charges. It says we billed and/or received payment for services that we were not entitled to. Therefore we are responsible for paying them back.

Can we appeal this? If so how?  What do we need to say or do to appeal this and win?

Help???

Thanks!

[Michele]

You can file an appeal, but the overpayment should be reimbursed, then the claim should be appealed.  Medicare doesn't mess around with getting overpayments returned.  As for the appeal, I would write up your reason/argument for disagreeing with their decision and submit any supporting documentation with it.  I can't really tell you much since I don't know what the services were, what type of provider it is, etc.

Michele

[dfranklin]

Michelle,

My provider is a chiro.

They say they overpaid due to the number of services.

Here is a letter he has created for part of it (I took out patient data etc). Will this work? ANd should we include the XRAY report and exam findings?  What else do we need to do and how do we go about this correctly? 


To: Medicare PA

Date: 1/19/2010

RE: Overpayment for services.

   I have received your letter stating that overpayment was made. After careful review of the letter sent. I disagree with the determination that there was overpayment.

The first claim was XXXXXXXXXXXX   For JANE DOE    Hic No. XXXXXXXXX

The reason for overpayment was given as incorrect information concerning the number of services or entry of charges.

On December 17, 2007 Ms. XXXX reported neck pain dizziness and hip pain.
Based on her exam and X-ray findings she was adjusted at Occiputt, Cervical 1, Cervical 5, thoracic 2, thoracic 6, and thoracic 10 Lumbar 4, and Sacral Left

The code that was submitted was 98941. That is appropriate for this number of areas adjusted.

On December 19, 2007 Ms. XXXXX reported neck pain dizziness and hip pain.
Improvement was noted due to previous adjustment.
Based on her exam and X-ray findings she was adjusted at Occiput, Cervical 5, thoracic 2, thoracic 6, Lumbar 4, and Sacral Left

The code that was submitted was 98941. That is appropriate for this number of areas adjusted

On December 21, 2007 Ms. Keller reported neck pain dizziness and hip pain.
Based on her exam and X-ray findings she was adjusted at Cervical 1, Cervical 5, thoracic 6, and thoracic 10 Lumbar 4, and Sacral Left

The code that was submitted was 98941. That is appropriate for this number of areas adjusted.

On December 26, 2007 Ms. XXXXX reported neck pain dizziness and hip pain.
Based on her exam and X-ray findings she was adjusted at Cervical 5, thoracic 5, and thoracic 10 Lumbar 4, and Sacral Left

The code that was submitted was 98941. That is appropriate for this number of areas adjusted.

On December 28, 2007 Ms. XXXX reported neck pain dizziness. Improvement was noted in her symptom due to previous visits.
Based on her exam and X-ray findings she was adjusted at Cervical 1, Cervical 5
The code that was submitted was 98940. That is appropriate for this number of areas adjusted.


Each day the patient was adjusted based on her X-ray examination findings. The number of sites listed do correlate to the number of sites adjusted. The care was appropriate and reasonable.



Dr. XYZ
Doctor of Chiropractic
Board Certified Clinical Nutritionist

[Michele]

Are they denying for the number of visits the patients received in the year? 

In any case, the letter looks fine, but I would definitely include xrays, and dr notes on each patient.

Michele

[PMRNC]

I save the notes and or other attachments for a second appeal if needed/requested. With each appeal you MUST include supported documentation MORE than what was presented with the original claim. If you show it all on the first appeal and they deny you have nothing more to add. I usually send a letter and if the service is covered to begin with they will either pay or request the notes.

[dfranklin]

They have 3 different invoice numbers they are requesting reimbursement on their one request (2 different patients). The provider has written 2 letters for the appeal (one for each patient). Can I send the letters together for the appeal since it is one Overpayment request? 

Should I write up a seperate letter or just send the provider's 2 letters?  Should I send it regular mail or should I send it in any special way? Signature requested, etc?

This is my first appeal or response to an Overpayment request. 

Thanks!

[Michele]

I would include them together in the envelope, but separated (not mixed up).  Staple, or clip all papers for one patient together, and the other one separate.  I would make copies of everything prior to sending it.  Personally I don't mail any special way, because I use to work at a major insurance carrier and anyone in the mail room could sign.  When someone called and said "I sent it return receipt and I have a signed paper" there was no way we could track it, and there was no way to find the papers.  I make copies so I can resend if it isn't received. 

Michele

[PMRNC]

I was a claim tech which was next to a supervisor and I used to sign for mail all the time if it had my name or even my dept on it. But if there is no specific name, then anyone in the mail receiving can sign.