Cancel the original claim and submit the claim to the VA. Once the canceled claim has processed, the Fiscal Intermediary Standard System (FISS) will automatically recoup the money you were paid.

Where the VA authorized services, Medicare does not make payment for items or services furnished by a non-Federal provider pursuant to such an authorization. Although certain MSP billing procedures apply, VA is not an MSP provision.

Reference

A post-payment review is conducted on services / claims that have already been submitted and paid by Medicare to the provider. First Coast is required to review documentation that substantiates information reported on claims submitted for reimbursement. We do this to ensure that the Medicare program reimburses only for covered, medically necessary, items or services furnished to eligible beneficiaries by qualified providers or suppliers.

Upon completion of the TPE review, a summary letter will be mailed to you detailing the outcome of the review as well as individual claim review determinations. The summary letter will also request that you set up a one-on-one educational call with the nurse who reviewed the case to ensure your understanding of the results, how they were determined and, if applicable, how to improve the outcome for future medical reviews.

An Extended Repayment Schedule (ERS) can be requested if the debt cannot be paid in full. Follow instructions outlined in the Sole proprietor or Corporation/group ERS forms below and return the required documentation.  Once a completed ERS has been received, a 30 percent withholding of claim payments will begin, and the withholding will continue until the review has been completed. The original documents must be mailed with the payment.

CMS clarified in the Calendar Year (CY) 2024 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Final Rule that Medicare covers partial hospitalization program (PHP) services for the treatment of substance use disorders (SUDs).

LCDs and articles can be found by using the First Coast interactive LCD index.

In addition to using the interactive LCD index, First Coast’s LCDs and articles are available using the CMS Medicare Coverage Database. NCDs can also be found on the Medicare Coverage Database.

After notice of a valid appeal request, if limitation of recoupment (Section 935 of the Medicare Modernization Act) provisions apply, all collection activities are ceased, including the withholding of future claim payments. Interest, however, will continue to accrue during the appeal process.

Reference

The CMS Medicare Claims Processing Manual states:

Ambulance transports

Emergency or urgent situations: In general, a notifier may not issue an ABN to a beneficiary who has a medical emergency or is under similar duress. Forcing delivery of an ABN during an emergency may be considered coercive. ABN usage in the ER may be appropriate in some cases where the beneficiary is medically stable with no emergent health issues.

An overpayment letter is a formal request to repay a debt owed to the Medicare Trust Fund. Payment is due upon receipt of the notice. Send the payment with a copy of the overpayment letter received or request an immediate offset.  Interest will accrue 30 days from the date on the overpayment letter and every thirty days thereafter. On day 40, we will immediately begin offsetting and claim payments will be withheld and applied until the entire debt is collected.