The OIG has instructed MACs to recoup the entire DRG payment on claims dating back to 2016.
EDITOR’S NOTE: The RACmonitor special bulletin of Jan. 30, “News Alert: Widespread Recoupments of Incorrect Post-Acute Transfer Claims Have Begun,” is prompting alarm among hospitals, as evidenced by the response from Dr. R. Phillip Baker.
In response to the directive issued by U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), in which the federal healthcare watchdog has instructed Medicare Administrative Contractors (MACs) to recoup the entire DRG payment on claims dating back to 2016, Dr. R. Phillip Baker, a physician advisor, is urging physicians to take immediate action.
“The recoupment is completely out of proportion to the error, as the normal finding would only result in the recoupment of the difference between the actual payment and what should have been paid with the correct code on the claim,” Baker said in an email to RACmonitor. “For the most part, the denial is correct, and an error occurred on the claim, so the standard appeal process would not help.”
The other issue, according to Baker, is that these claims are well beyond the time frame for filing a corrected claim, so there is no way to lessen the impact through that process.
“The letter (results of the OIG audit on disposition codes) issued does allow a rebuttal process, but you only have 15 days to use this option from the date of the letter,” Baker said. “I spoke with Dr. Toni Sculimbrene at Palmetto, GBA, who advised that the rebuttal process should be utilized, as the MAC has no other option for stopping the recoupment.”
According to Baker, as stated in the letter, “a rebuttal is not intended to review supporting medical documentation, nor disagreement with the overpayment decision. A rebuttal shall not duplicate the redetermination process.” The rebuttal, he noted, is to address that the recoupment was not done using the correct methodology, as it should, but only addresses the part of the payment that was incorrect (rather than the entire payment).
“I have also reached out to the South Carolina Hospital Association, and encourage you to reach out to your state associations and the American Hospital Association (AHA) to encourage their involvement,” Baker said. “The more complaints issued about this unfair and inappropriate process, (the more it) will make the Centers for Medicare & Medicaid Services (CMS) and the OIG have to take notice and address the issue. It is only by everyone filing these rebuttals that the process can change to be fair.”
Baker urged fellow physicians that if they have cases they find were inappropriately denied, then they also need to follow the redetermination process also addressed in the letter.
“You do not want to miss the time frames that apply to that as well,” Baker urged. “Even if this is the case, still, file the rebuttal about the issue of recouping the entire payment.”
I am happy to report that there is no major controversy to report on this week. So let me address issues that came up with
This month, the Secretary of the U.S. Department of Health and Human Services (HHS) – Robert F. Kennedy, Jr. – testified at seven congressional committee
Please log in to your account to comment on this article.
Breast biopsy procedures may be clinically straightforward but accurately translating them into compliant billing can be anything but. In this focused webcast, Shawn Blackburn, CPC, CPMA, CIC, CRC, CCS-P breaks down how imaging guidance, lesion count, laterality, and payer expectations all impact how these procedures should be reported. Through clear explanations and real-world scenarios, you’ll gain practical insight into aligning clinical workflows with billing requirements, avoiding common pitfalls, and ensuring your documentation supports accurate reimbursement and compliance.
Gain clarity and confidence in OB‑GYN coding with this expert‑led webcast featuring Sherri L. Clayton, RHIT, CSS. You’ll learn how to apply global maternity package rules accurately, select the right CPT codes for procedures and visits, and identify documentation gaps that lead to denials. With practical guidance and real examples, this session helps you strengthen compliance, reduce audit risk, and ensure accurate reimbursement for women’s health services.
Uncover essential coding insights with nationally recognized coding authority Kay Piper, RHIA, CDIP, CCS. Through ICD10monitor’s interactive, on‑demand webcast series, Kay walks you through the AHA’s 2026 ICD‑10‑CM/PCS Quarterly Coding Clinics, translating each update into practical, easy‑to‑apply guidance designed to sharpen precision, ensure compliance, and strengthen day‑to‑day decision‑making. Available shortly after each official release.
Uncover critical guidance on the ICD-10-CM/PCS code updates. Kay Piper reviews and explains ICD-10-CM/PCS coding guidelines in the AHA’s fourth quarter 2026 ICD-10-CM/PCS Coding Clinic in an easy to access on-demand webcast.
Traditional utilization management models can no longer keep pace with regulatory shifts, payer scrutiny, and operational pressures. In this webcast, Tiffany Ferguson, LMSW, CMAC, ACM, ACPA-C, introduces an Adaptive Model strategy that modernizes UM through role specialization, technology-driven workflows, and proactive, team-based processes. Attendees will learn how to restructure programs to improve efficiency, strengthen clinical collaboration, and enhance financial performance in a rapidly changing healthcare environment.
Federal auditors are intensifying their focus on inpatient psychiatric facilities, using advanced data analytics to spotlight outliers and pursue high‑dollar repayments. In this high‑impact webcast, Michael Calahan, PA, MBA, Compliance Officer and V.P., Hospital & Physician Compliance, breaks down what regulators are really targeting in IPF-PPS admissions, documentation, treatment and discharge planning. Attendees will learn practical steps to tighten processes, avoid common audit triggers and protect reimbursement and reduce the risk of multimillion-dollar repayment demands.
In this timely session, Stacey Shillito, CDIP, CPMA, CCS, CCS-P, CPEDC, COPC, breaks down the complexities of Medical Decision Making (MDM) documentation so providers can confidently capture the true complexity of their care. Attendees will learn practical, efficient strategies to ensure documentation aligns with current E/M guidelines, supports accurate coding, and reduces audit risk, all without adding to charting time.
Join Ronald Hirsch, MD, FACP, CHCQM for The PEPPER Returns – Risk and Opportunity at Your Fingertips, a practical webcast that demystifies the PEPPER and shows you how to turn complex claims data into actionable insights. Dr. Hirsch will explain how to interpret key measures, identify compliance risks, uncover missed revenue opportunities, and understand new updates in the PEPPER, all to help your organization stay ahead of audits and use this powerful data proactively.
Celebrate Lab Week with MedLearn! Sign up to win one year of our Laboratory All Access Pass! Click here to learn more →
Have a Medicare regulation question you’d love Dr. Hirsch to answer? Now is your chance! CLICK HERE to learn more→
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 1 with code CYBER25
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
