“I am a retired DPM and closed my business. Medicare is wanting recoupment on some DME items from 3 years ago. They can’t recoup it through the claims obviously since I’m not practicing. They are asking me to directly send in the money. Do I need to pay this and then appeal? Should I appeal and not pay? What are the rules in this situation?”
This is a scenario that many physicians face while in practice. Who would ever think that this would be an issue once the physician has retired from active practice? CMS/Medicare has the right to recoup what they consider to be an “inappropriate reimbursement” up to 3 years or even longer after the reimbursement was originally made. Unfortunately, retiring from active practice is not an excuse or an escape from the process.
I have found a really good source of information that covers this situation. It is the Medicare Learning Network, “Medicare Overpayments,” MLN006379 July 2022. The following is some key information taken directly from the publication:
An overpayment is a payment made by CMS to a provider that exceeds the amount due and payable according to existing laws and regulations. Identified overpayments are debts owed to the federal government. Laws and regulations require us to recover overpayments. This fact sheet describes the overpayment collection process.
Overpayments happen because of:
- Incorrect coding
- Insufficient documentation
- Medical necessity errors
- Processing and administrative errors
Overpayments are identified by CMS, 1 of its contractors, or self-reported by a provider.
Overpayment Collection:
Demand Letter
When a provider receives an overpayment of $25 or more, its MAC initiates the overpayment recovery process by sending a demand letter requiring repayment. Find your MAC’s (Medicare Administrative Contractor’s) website for more information.
A MAC demand letter includes information relating to the following:
- That an overpayment was made
- How the overpayment was calculated
- Name and MBI of patient involved
- Dates and types of services overpaid
- How interest will accrue, and what rate (if the overpayment isn’t repaid in full within 30 days)
- Extended repayment schedule (ERS)
The recoupment process and options (for example, when recoupment will start, the ability to request immediate recoupment, the impact of filing an appeal on recoupment)
- Rebuttal rights (if applicable)
- Administrative appeal rights
- We may instruct the Medicaid State Agency to withhold the federal share of any Medicaid payments until the full amount owed to Medicare is recouped
A provider may choose from these options when responding to an initial demand letter:
- Make an immediate payment
- Request immediate recoupment
- Submit a rebuttal
- Appeal the overpayment by requesting a redetermination
- Request an ERS: Extended Repayment Schedule- The Extended Repayment Schedule (ERS) is a payment option for Medicare providers who have received an overpayment notice and are unable to repay the full amount within 30 days due to financial hardship. It allows providers to repay the overpayment in installments over an extended period, rather than in a lump sum, helping them maintain their cash flow.
If the provider’s initial demand letter is returned to their respective MAC as undeliverable, the MAC will attempt to reach the provider by phone within 10 business days of receiving the initial demand letter.
Payment Options:
-Immediate Recoupment
-Standard Recoupment
-ERS
Obviously, all of the above are not options due to the fact that the provider is retired.
Other Options:
Rebuttal: A provider may submit a rebuttal within 15 calendar days from the date of the MAC’s demand letter. The rebuttal explains and provides evidence why the MAC shouldn’t recoup the payment. The MAC will promptly evaluate your rebuttal statement.
Note: A rebuttal is different than an appeal and doesn’t stop recoupment activities.
- Appeal: If a provider disagrees with an overpayment decision, they can request an appeal. Medicare Part A and Part B has 5 appeal levels:
1) Redetermination occurs after the initial Part A and Part B claims determination. A MAC re-examines the claim and supporting documentation. A MAC employee not involved in the initial determination makes the redetermination.
2) Reconsideration by a Qualified Independent Contractor (QIC).
3) Hearing by an Administrative Law Judge (ALJ) or review by an Attorney Adjudicator at the Office of Medicare Hearings and Appeals (OMHA).
4) Review by the Medicare Appeals Council.
5) Judicial Review in U.S. District Court.
I have only provided some information taken directly from the MLN publication that addresses this situation. You might consider contacting the malpractice insurance carrier that you were insured by while you were in active practice and ask if they can put you in contact with someone that can assist you in making the most appropriate decision regarding this matter.
Michael G. Warshaw, DPM, CPC
THE 2025 PODIATRY CODING MANUAL IS STILL AVAILABLE in either Book or Flash-drive formats. It has been completely updated for the calendar year 2025. Many offices across the country consider this to be their “Bible” when it comes to coding, billing, and documentation. The price is still only 125.00 including shipping! To
purchase, access the website drmikethecoder.com.
No credit card? No problem! Just send a check for 125.00 to the following address:
Dr. Michael G. Warshaw
2027 Bayside Avenue
Mount Dora, Florida 32757
Read Comments