When a provider determines that a Medicare overpayment exists, the following steps must occur.

Complete the Return of Monies Voluntary Refund Form

In order to ensure the MSP refund is properly processed, a copy of the other insurer’s EOB and/or payment information (i.e., a copy of the check) is required to calculate the Medicare Secondary payment. When the Medicare Secondary payment is calculated, it will determine if the refund amount is correct or there is an additional balance due.

First Coast accepts medical records via: 

The Initial Notification Letter includes a documentation checklist to help providers prepare documentation for submission. The documentation checklist can also be found under targeted probe and educate review topics and schedule of review.

Once an ADR is received, a provider should do the following:

(Additionally, when the physician decides the patient should be in observation without prompting by the utilization review (UR) committee or case management and prior to the discharge of the patient and submission of the claim.)

No. When a physician orders a patient to be placed under observation, the patient's status is outpatient. The purpose of observation is to determine the need for further treatment or for inpatient admission.

Medicare Secondary Payer (MSP) overpayments are processed differently than non-MSP overpayments and require a refund to be sent within sixty days of receiving a duplicate payment. Complete the appropriate Medicare Secondary Payer return of monies voluntary refund form (see below) and attach a check for the overpaid amount. In addition, the other insurer’s explanation of benefits and/or payment information is required for every claim involved.

Providers are required to pay Medicare within 60 days from the date a payment is received from another payer (primary to Medicare) for the same service for which Medicare paid.

However, if a demand letter is needed by the provider’s accounting department, submit the MSP Overpayment Refund form and the other insurer’s EOB and/or payment information (e.g., a copy of the check) to Medicare.

No, hospitals are required to notify patients who have used or will use 90 days of benefits that they can choose not to use their reserve days for all or part of a stay. The hospital notice should be given when the beneficiary has five regular coinsurance days left and is expected to be hospitalized beyond that period. If the hospital discovers the patient has fewer than five regular coinsurance days left, it should immediately notify the patient of this option. The hospital should notate when it informed the patient of this option.