When you receive an overpayment demand letter from Medicare and disagree with the decision, there are two options for how to respond. You can submit either a rebuttal or an appeal. Your rebuttal and appeal rights will be clearly listed on the demand letter.
According to the Medicare Administrative Contractor (MAC) WPA-GHA, “The purpose of a rebuttal is not to provide supporting medical documentation for review nor to disagree with the overpayment decision.” Rather, rebuttals give providers the chance to explain why they believe Medicare should not recoup an overpayment when specified. They often involve a problem or change with a Medicare Secondary Payer.
To submit an overpayment rebuttal statement, providers should include the following in their request:
- Rebuttal statement and pertinent supporting evidence
- Provider/physician/supplier’s Provider Transaction Access Number (PTAN)
- Provider/physician/supplier’s National Provider Identifier (NPI)
- Demand letter number
Rebuttals should be made by Day 15 after the MAC identifies an overpayment. The MAC will then consider the rebuttal within 15 days of receiving it and send a written notice of their decision and rationale. A rebuttal does not automatically stop the recoupment process, and once the MAC responds to the rebuttal, the decision cannot be appealed.
For more information about Overpayment Rebuttals, check out the WPS-GHA Overpayment Rebuttals Statement webpage.
Unlike rebuttals, appeals allow providers to disagree with an overpayment decision and to submit supporting medical documentation for review.
An appeal can temporarily halt the recoupment process if providers submit redetermination requests within 30 days of the demand letter date. If the redetermination decision continues to support the overpayment, providers still have 60 days from the date of that decision to submit a reconsideration request, which will also continue to delay the recoupment.
WPS-GHA offers the following tips to ensure overpayment appeals are received and processed correctly:
- Make it clear you are appealing an overpayment by using the Redetermination of an Overpayment Request Form.
- Include the date of the initial overpayment letter on the request form.
- Always include a copy of your overpayment letter.
- Submit your overpayment appeal request right away. As noted above, appeals must be received within 30 days for the recoupment to be paused.
Overpayment appeals can be mailed or faxed using the address or fax number on the overpayment redetermination request form. You can also submit an overpayment appeal using the WPS Government Health Administrators Portal. Mark “Yes” next to the “Request involves Overpayment” question. Appeals cannot be emailed.
For more information about Overpayment Appeals, check out the WPS-GHA ow to Appeal an Overpayment Decision Webpage.
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