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	LHRH Recoupment Alert By Rick Rutherford Director – Practice Management, AUA

CUA Members:

Around June 19, 2007, several of you notified us about Medicare remittance notices from NHIC Corporation that were followed by demand letters from PRG Schultz (the California Recovery Audit Contractor) requesting repayments of overpayments for prostate cancer drugs during the period from late 2002 through the middle of 2003.

Based on the examples of the demand letter we have seen, the alleged overpayments stem from NHIC’s misapplication of the least costly alternative (LCA) policies that govern the amount of payment for luteinizing hormone-refractory hormone drugs in your Medicare region. Urology practices are being asked to repay amounts in the thousands of dollars and you have only been given three weeks to comply.

Because the accuracy of patient lists and amounts issued by the carrier have historically been in question, we suggest that you undertake the steps outlined below. In other states, urologists have prevailed in arguing that such overpayments were the fault of the carrier and therefore the providers should not be forced to pay since they complied with the rules as they understood them.

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Immediately send a letter back to the carrier acknowledging receipt and indicating that you intend to appeal. This letter should be sent to NHIC Overpayment, NHIC Redeterminations, P.O. Box 272854, Chico, CA 95297-2851. Enclose copies of each demand letter that you have received to date. NOTE: These letters identify each patient by name and claim control number. If all you have received so far are Medicare remittances with large lists of overpaid claims for multiple patients, you should wait for the demand letters that follow.

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In your letter, include the following:

“Our billing and medical records staff is inadequate to perform sufficient research on such a large number of demands for overpayment. We respectfully request an additional ninety (90) days to research the patient records included in these letters before we are required to pay any funds back to you or before interest begins to accrue. We are aware that in previous instances where Medicare carriers have issued such mass requests, the patient lists issued contained patients that were not actually overpaid and even patients that had not received the drugs in question. We contend that the RAC contractor, PRG Schultz, may have exceeded the scope of work in their CMS contract undertaking these actions and therefore, has not complied with the contractual protocols for investigating alleged overpayments. Therefore we need the additional time to conduct a complete audit of the alleged overpayments to ascertain accuracy and to understand our legal rights. Since the dates of payment were so long ago, this will require pulling information out of our archives which will be labor intensive and time consuming.”

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Communicate with your state representatives and your Congressional delegation and ask for their assistance in convincing NHIC to postpone recoupment and interest charges on these funds until you have had adequate time to prepare a defense. Include a copy of one of the demand letters (with patient identifying information redacted) and a copy of your appeal letter.

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With the assistance of the California Urological Society, the California Medical Association, and/or the AMA; we recommend you band together and seek legal assistance on your rights of appeal in this matter. We contend that the burden to comply with the LCA policies rests equally on the providers and the carriers and that it is unfair to expect the providers to bear the entire financial burden for errors in processing. We are also communicating with Jeffrey Kaufman, M.D., the Carrier Advisory Committee urologist for California and with CMS officials in Baltimore, Maryland about this issue since the contract with PRG Schultz is held directly with CMS. With the right legal advice, an injunction barring PRG Schultz from recouping this money may be possible and/or a settlement may be achieved that reduces or eliminates the amount you are expected to repay.

We will continue to monitor this situation on your behalf and we will attempt to keep you advised of progress as we are made aware of it. If you have further questions or concerns, please send us a message at pracman@auanet.org or call us at 410-689-3924. It is not necessary to send us copies of the correspondence you have received from NHIC or PRG Schultz on this issue. We have sufficient examples already.

Rick Rutherford
Director – Practice Management