Below is a sample letter that may be used in response to an inaccurate post payment overpayment notice from a payer. The letter should be customized for the specifics of the post payment request. 

Some states have laws that limit the timeframes for post payment reviews and recoupments. Groups should consult with experienced healthcare counsel and review their state laws for any provisions that impact the audit process. Furthermore, if there is a contract in place with the payer then the applicable payer contract policies, procedures, and manual provisions regarding audits and take-backs should be reviewed.

 

INCORRECT POST PAYMENT REVIEW - SAMPLE LETTER

Date

Attn:
Provider Appeals Department
Address
City, State, ZIP Code

Re: Post payment refund requests based on incorrect coding audits

 

Health Plan ID Number:	Group Number:
Insured/Plan Member:	Patient Name:
Claim Number:	Claim Date:

Dear Sir/Madam:

{Insert physician group name here}, is deeply concerned about {insert insurance company name here}’s allegation that {insert physician group name here} incorrectly coded claims submitted to {insert insurance company name here} and the assertion that an overpayment in the amount of $_________ has been made to {insert physician group name here}. As a basic matter, we ask that you provide the statutory and contractual basis upon which {insert insurance company name here} conducted its audit and is seeking repayment. We also request information as to how the charts were selected, and to confirm that a coder reviewed each of the audited records. 

If generative AI and/or machine learning (AI) was used for claim or coding review, please describe in detail how the AI was developed, deployed, reviewed and the extent if any that professional coders, billers and/or clinicians have reviewed some or all of the AI results.  If changes were made because of such a review, please describe the changes in detail.   

In order to meaningfully respond in a productive manner, {insert physician group name here} requests an explanation as to the basis of the coding disagreement for each and every claim that was allegedly overcoded. {Insert physician group name here} believes its coding appropriately reflects the medical decision-making and treatment provided based on the patient’s clinical presentation, as documented in the medical records.

{Insert insurance company name here}’s findings do not specify the underlying basis for its determination that documentation within the medical records did not meet the requirements for the Evaluation and Management (E&M) code billed. Rather, only a generalized comment of _____________________ was provided as the basis of {insert insurance company name here}’s decision.  Accordingly, we ask that you provide the specific rationale that mandates the lower level of coding for each downcoded claim.  Once {insert physician group name here} is provided the detailed basis of the downcoding, including how the coder determined the medical decision-making and associated Evaluation and Management code, it will fully address the specific coding for each downcoded claim.

{Insert physician group name here} disputes the audit findings, disagrees that it owes $___________, and does not agree that any payment is due nor that {insert insurance company name here} has the right to offset any future payments. 

We look forward to your response and addressing any of your coding concerns. Please feel free to contact me for any further information you may require.

Sincerely,

 

[Physician Name]

 

Appendix A

States That Have Established Time Limits on the Detection and Recovery of Overpayments

 

Alabama (Code of Alabama 27-1-17)	Missouri (HB 328 & 88, 2001)
Arizona (Insurance Code 20-462)	New Hampshire (Insurance Code 420-J:8-b)
California (Safety Code Sec. 1371)	Ohio (Insurance Code 3901.38.8)
Colorado (HB 99-1250, 1999)	Oklahoma (HB 1745, 1999)
Florida (State Statutes 627.6131, 2003)	Texas (Insurance Code Title 28, 21.2805)
Georgia (Annotated Code 33-29-3)	Utah (SB 69, 2001)
Iowa (Admin. Code 191-15.32 (507B))	Virginia (Insurance Code 38-2-3407.15)
Kentucky (SB 279, 2000)	Washington (SB 6184, 2004)
Louisiana (HB 2052, 1999)	West Virginia (Insurance Code 33-45-2)
Maryland (SB 335, 1997)