Q: My facility is going through a Medicare UPIC review and received several denials followed by a demand letter requiring repayment. What are options for appealing and paying?

A: When there is an overpayment of $25 or more, the MAC will initiate the overpayment recovery process with a letter.

The demand letter should outline key information including the specifics of the overpayment, as well as the recoupment process. The current interest rate is 11.5% and will be applied to unpaid overpayment balances beginning on day 31 from the date of the demand letter.

The letter will discuss rebuttal rights and administrative appeal rights, and possibly instruct the state agency to withhold the federal share of any Medicaid payments until the full amount is recouped. Submitting a rebuttal does not stop recoupment activities. But submitting an appeal by day 30 from the date of the demand letter will stop the recoupment process. 

Even so, interest continues to accrue. If a redetermination appeal is received after day 30, but before day 120, the MAC is required to stop recoupment when it receives and validates your appeal. In this case, the MAC will not refund money already recouped, but will not continue recoupment until the redetermination process is adjudicated. 

Following an unfavorable or partially favorable redetermination decision, a reconsideration appeal may be filed with the Qualified Independent Contractor (QIC) within 60 days from the redetermination decision letter date to stop the recoupment process. After the QIC’s initial decision or dismissal, the recoupment process will resume for any overpayment amount not previously paid in full, regardless of whether the provider submits appeals at further appeal levels.