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Federal and Commercial Payor Medical Record Requests are Important – Don’t Dismiss Them!

First few Article Sentences

It is becoming more and more common for providers to receive what appear to be innocuous medical records requests from both federal and commercial payors. These requests are typically based on data analytics available to the payor that identify the provider as an outlier in some respect. Payors use the analytics to look for potential overpayment issues. Unfortunately, most providers do not understand the significance of these requests and the impact that an incomplete response can have on a future potential overpayment demand and/or possible imposition of a payment suspension by Medicare or a commercial payor.

Unified Program Integrity Contractors (UPICs), operating on behalf of Medicare, can reopen claims for good cause pursuant to 42 CFR 405.986. Commercial payors usually have similar contractual provisions that allow them to reopen claims or seek reimbursement of claims that the payor believes were improperly paid.

Cooper, Esq., Richard S.


McDonald Hopkins LLC

Law, Medical Records

June 5, 2018

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