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Thread: Expectation after Internal Chart Reviews

  1. #1
    Join Date
    Apr 2007

    Default Expectation after Internal Chart Reviews

    AAPC: Back to School
    We conduct a monthly internal chart review. We have been using the results as a teaching tool for the physicians but have never taken any action with the insuracne companies regarding overcoding. If we conduct an internal chart review and find overcoding are we expected/required to reimburse the insurance company for the overpayments?

  2. #2
    Join Date
    Apr 2007
    Columbus, OH

    Unhappy voluntary refund of overpayments

    Per our legal department, we are obligated to refund any overpayments we discover in an internal audit due to incorrect or up-coding of claims. Further, if we determine a pattern of incorrect coding, we are obligated to review all claims submitted in the past with this error and refund any resulting overpayments. Needless to say, this can be the proverbial "can of worms" so I do PRE-payment audits exclusively now!
    Melanie Zinser, RMC, CPMA, CPC-I, CANPC
    Coding Educator & Quality Analyst
    OhioHealth Physician Group

  3. #3
    Join Date
    Apr 2007

    Default Voluntary refund of overpayments

    Thank-you for the response and the good advice. If we only do prospective audits we would never need to worry about returning overpayments.

  4. #4


    Just a note........would hate for an external auditor to conclude that the practice is intentionally manipulating their internal coding audit program

    The coding audit program is (or should be) based on the internal compliance plan. How is your audit program spelled out in the company compliance plan.

    One of the problems (and I know it well) is when the auditor under the rule of the business office and they hate returning money. The BO should not have the authority to pull you off of post-payment audits or re-focus your audits to whatever suits them best

  5. #5
    Join Date
    Apr 2007
    Indianapolis, IN


    I just happened to see this today after reading the attached below -
    Per AMA regarding the health reform bill -
    "Effective March 24, 2010

    A physician who has received a Medicare or Medicaid overpayment is required to report and return that overpayment to the HHS secretary, the state, an intermediary, a carrier, or a contractor, as appropriate, at the correct address. As part of the notification, the physician is required to specify in writing the reason for the overpayment. An overpayment must be reported and returned within 60 days after it was identified. The statute defines the term "overpayment" to mean any funds that a person receives or retains under Medicare or Medicaid to which the person, "after applicable reconciliation," is not entitled. Clarification has not been provided by the HHS secretary on the process for returning overpayments or on the meaning of the statute's phrase "applicable reconciliation." However, failure to comply with this provision could result in significant liability. As a result, physicians should consult with legal counsel, if appropriate. Those who believe they have received an overpayment should, at a minimum, immediately contact their contractor to obtain additional guidance, preferably in writing. "

    Hope this helps!

  6. #6
    Join Date
    Apr 2007


    At my practice, it is written and practiced in our compliance plan that in the event of discovery of an overpayment, we practice self-disclosure, we refund the monies immediately. I am very fortunate to work at a practice that adheres to their compliance plan.

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