How is it determined that an overpayment was identified?
CGI will identify a claims overpayment where there is supportable evidence of the overpayment. There are two primary ways of identification: 1. Through automated review of claims data without human review of medical or other records 2. Through complex review which entails human review of a medical record or other documentation The determination process for identifying overpayments is summarized in four steps: CGI documents the rationale for the determination listing the review findings with a detailed description of the Medicare policy that was violated. The review goes through the validation process which may require further review from the MAC/FI/Carrier but essentially routes to CMS for final validation. CGI communicates with the provider about improper payment (Review Results Letter). Depending on whether the determination is either a full or partial denial, the overpayment amount is determined.
CGI will identify a claims overpayment where there is supportable evidence of the overpayment. There are two primary ways of identification: 1. Through automated review of claims data without human review of medical or other records 2. Through complex review which entails human review of a medical record or other documentation The determination process for identifying overpayments is summarized in four steps: CGI documents the rationale for the determination listing the review findings with a detailed description of the Medicare policy that was violated. The review goes through the validation process which may require further review from the Medicare Administrative Contractor/FI/Carrier but essentially routes to CMS for final validation. CGI communicates with the provider about improper payment (Review Results Letter). Depending on whether the determination is either a full or partial denial, the overpayment amount is determined.
Related Questions
- Will PERS help individual members with possible tax issues associated with the overpayment and potential tax consequences and penalties associated with repayments?
- Will the actuarial reduction end when the member has fully repaid the overpayment from the 1999 earnings allocation (calculated as of the benefit adjustment date)?
- What happens if there is an overpayment?
