Appeal of UPIC Audit Overpayment Determinations – A Multi-Step Approach

Medicare providers are constantly having their medical records audited, whether on a pre-payment or post-payment basis, by their Medicare Administrative Contractor (“MAC”) or by a Unified Program Integrity Contractor (“UPIC”). The purpose of the audit is to ensure compliance with Medicare reimbursement coverage policies, including but not limited to National and Local Coverage Determinations (NCDs or LCDs) as well as compliance with the various Medicare manuals related to benefit, coverage and claims processing. The challenge for providers is to insure that a timely response is submitted along with completeness of records pertinent to the records being sought.

In the event an unfavorable review occurs, provider’s will receive a audit findings summarizing the UPICs basis for believing payment to the provider should be denied and/or should be recouped via an overpayment determination. Thereafter, the MAC will issue a demand letter based on the UPIC’s findings and will request that the provider repay any reimbursement funds its received for the claims at issue, as well as instructing the provider of their right to file an appeal (a redetermination request).

Undersigned counsel’s experience with Medicare audits and appeals has allowed for a multi-step approach to challenging audit findings and purported overpayment amounts, including the filing of timely appeals to insure that the provider’s Medicare cash flows remain uninterrupted at the redetermination and reconsideration levels, the preparation of an extended payment request if necessary, and an organized presentation of the medical records supported by Medicare coverage and reimbursement policies. Mr. Gaitan’s experience has allowed his clients to remain open with minimal financial disruption and has successfully challenged overpayment determinations whether extrapolated overpayments or actual dollar overpayments, resulting in significant reductions to monies owed to the Medicare program and refund of any monies recouped from the provider by the Medicare program.

In August, Mr. Gaitan received a mostly favorable Administrative Law Judge (ALJ) decision on an overpayment determination issued against a home health agency (HHA), that resulted in eight of ten claims being reversed. In this same case, Mr. Gaitan had previously received other favorable decisions at the redetermination level (MAC) and reconsideration level (Qualified Independent Contractor “QIC”) which reduced the extrapolated overpayment of $400,000 to $23,000 left for dispute at the ALJ. After the ALJ decision, the HHA will owe approximately $3,000.00 to the Medicare program.

Mr. Gaitan is available to discuss his strategies and legal costs, including hourly and contingency fee arrangements with provider’s who have received a records request or have received an overpayment determination and demand letter from their MAC or would like to more about the process. Initial consultation fee is waived. Feel free to contact Rafael (Ralph) Gaitan, Esq. at (786) 440-8115 or via email at [email protected]