243364 3 /18/2015 y u,,C�F'y
CITY OF CARMEL, INDIANA VENDOR: 369203
�/ ( ONE CIVIC SQUARE WISCONSIN PHYSICIANS SERVICE INS GtJ CK AMOUNT: $*******274.78*
9 ,�=�; CARMEL, INDIANA 46032 PO BOX 8811 CHECK NUMBER: 243364
;,,�roN�� MARION IL 62959 CHECK DATE: 03/18/15
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
102 5023990 274.78 OTHER EXPENSES
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ITY : 0 CARMEL
JAMES BRAINARD, MAYOR
March 12, 2015
Wisconsin Physicians Service Ins. Corp
P.O. Box 8811
Marion, IL 62959
RE : Claim#221814183380650#20143213:1 Lula Masters
Dear Medicare B Recovery Unit:
We have received your letter 15335081 for Lula Masters. Reason for overpayment:
Medicare paid this claim in error. The patient is currently living in a Skilled Nursing
Facility. The overpayment is$ 274.78 to be sent to Medicare B Recovery.
If you have any questions,please feel free to contact me at (3 17) 571-2604.
Sincerely,
��zl�
Michelle T. Harrington
EMS Billing Administrator
CARMEL FIRE DEPARTMENT
STEVEN A. CouTs HEADQUARTERS
Two Cmc SQUARE, CARMEL, IN 46032 OFFICE 317.571.2600, FAx 317.571.2615
<{ :..... MEDICARE
> : ..
::.... Part B
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Letter Number: 15335081
Date: 02/24/2015
CITY OF CARMEL
2 CIVIC SQUARE
CARMEL, IN 460322584
FIRST REQUEST
RE : MMA 935 - Overpayment Amount
Provider Name: CITY OF CARMEL
Provider Number: 1154325579
Outstanding Balance: $274.78
Dear Sir/Madam,
This is to inform you that you have received a Medicare payment in error„which has
resulted in an overpayment of$274.78. This amount is subject to Section 935(f)(2) of the
Medicare Modernization Act (MMA) (Section 1893(f)(2) of the Social Security Act),
Limitation on Recoupment. The purpose of our letter is to request that this amount be
repaid to our office. The attached listing explains how this happened.
Why you are responsible:
You are responsible for being aware of correct claim filing procedures. In this situation, you
billed and/or received payment for services you should have known you were not entitled to.
Therefore, you are not without fault and are responsible for repaying the overpayment amount.
If you dispute this determination please follow the appropriate appeals process listed below.
Applicable authorities: Section 1870(b)(c) of the Social Security Act; Subsections 405.350 -
='--465:359=of-Titie-- -CFR,'Subsections 404:506=404:509; 404:51,0- arrd x"+04:51 P--uf Titie 20=of-- --=
the United States Code of Federal Regulations and 20 CFR.
What you should do:
Please return the overpaid amount to us by 03/25/2015 and no interest charge will be
assessed.
We request that you refund this amount in full. If you are unable to make refund of the entire
amount at this time, advise this office immediately so that we may determine if you are eligible
Wisconsin Physicians Service Ins. Corp.
P.O.Box 1787,Madison,WI 53701
www.wpsmedicare.com
Page 2
Date : 02/24/2015
Letter Number : 15335081
for a repayment plan. Any repayment plan (where one is approved) would run from the date of
this letter.
Make the check payable to Medicare Part B and send it with a copy of this letter to:
Wisconsin Physicians Service Ins. Corp.
P.O. Box 8811
Marion, IL 62959
You may elect to have your overpayment(s) repaid through the immediate recoupment process
and avoid paying by check or waiting for the standard recoupment process that begins on day
41 from date of the init al demand letter.A-request for immediate recoupment must be received —
in writing no later than the 16th day from the date of initial demand letter. You must specify
whether you are submitting:
1. A one-time request for the current overpayment and all future overpayments, or
2. A request for the current overpayment addressed in this demand letter only.
This process is voluntary and for your convenience. Your request must specifically state you
understand you are waiving potential receipt of interest payment pursuant to Section 1893(f)(2)
for the overpayments. Note: Such interest may be payable for certain overpayments reversed
at the Administrative Law Judge (ALJ) level or subsequent levels of appeal.
Visit our website at www.wpsmedicare.com for additional information and instructions for
Immediate Recoupment.
You may fax your request to the number mentioned at the end of this letter.
Payment Withholding:
If payment in full is not_ received_ by_03/25/2015, yments _to you can be withheld
-- – (Recoupment)Ontil�payrfient in full is received or if you have not submitted an acceptable
extended repayment request and/or a valid and timely appeal is received.
Please complete an extended repayment schedule (ERS) package if you are unable to make
full payment at this time, and would like to request an ERS. Details for completing the ERS
package are included on our Website at www.wpsmedicare.com. If you would like to receive
an ERS package by mail, please call the telephone number listed at the end of this letter.
Rebuttal Process:
Under our existing regulations 42 CFR section 405.374, Providers and other Suppliers will
have 15 days from the date of this demand letter to submit a statement of opportunity to
rebuttal. The rebuttal process provides the debtor the opportunity to submit a statement and/or
Page 3
Date : 02/24/2015
Letter Number : 15335081
evidence stating why recoupment should not be initiated. The outcome of the rebuttal process
could change how or if we recoup. If you have reason to believe the withhold should not occur
on 04/05/2015, you must notify this office before 03/10/2015. We will review your
documentation. Our office will advise you of our decision in 15 days from receipt of your
request. However, this is not an appeal of the overpayment determination, and it will not delay
recoupment before a rebuttal response has been rendered.
The rebuttal statement does not cease recoupment activities consistent with section 935 of the
MMA.
How to Stop Recoupment:
Even if the overpayment and any assessed interest has not been paid in full you can stop
Medicare from recouping any payments. If you act quickly and decidedly, Medicare will permit
providers to stop recoupment at two points. The first occurs if we receive a valid and timely
request for a redetermination within 30 days from the date of this letter. We will stop or delay
recoupment pending the results of the appeal.
We will again stop recoupment if, following an unfavorable or partially favorable
redetermination decision if you decide to act quickly and file a valid request for
reconsideration with the Qualified Independent Contractor (QIC). The address and details on
how to file a request for reconsideration will be included in the redetermination decision letter.
What are the timeframes to stop recoupment:
First Opportunity: To assist us in expeditiously stopping the recoupment process, we request
that you clearly indicate on your appeal request that this is a 935 overpayment appeal for a
redetermination to:
Wisconsin Physicians Service Ins. Corp. - 935 APPEALS
REDETERMINATION
-- -- — _— -- P:O.-Box 8833 - - --- – _ _ ---- — -
Appeals
Marion, IL 62959
Second Opportunity: If the redetermination decision is 1) unfavorable we can begin to
recoup no earlier than the 60th day from the date of the Medicare redetermination notice
(Medicare Appeal Decision Letter), or 2) if the decision is partially favorable we can begin to
recoup no earlier than the 60th day from the date of the Medicare revised overpayment
Notice/Revised Demand Letter. Therefore, it is important to act quickly and decidedly to limit
recoupment by requesting a valid and timely reconsideration within 60 days of the appropriate
notice/letter. The address and details on how to file a request for reconsideration will be
included in the redetermination decision letter.
What Happens following a reconsideration by a Qualified Independent Contractor (QIC):
Page 4
Date : 02/24/2015
Letter Number: 15335081
Following decision or dismissal by the QIC, if the debt has not been paid in full, we will begin
or resume recoupment whether or not you appeal to the next level of Administrative Law Judge
(ALJ).
NOTE: Even when recoupment is stopped, interest continues to accrue.
Interest Assessment:
If you do not refund in 30 days: In accordance with 42 CFR 405.378 simple interest at the rate
of 10.5 percent will be charged on the unpaid balance of the overpayment beginning on the
31st dayinteresf is catctJai��i-in 30::day-periods arid-is-assessed-for-each-fuII30=dwy-per d
that payment is not made on time. Thus, if payment is received 31 days from the date of final
determination, one 30-day period of interest will be charged. Each payment will be applied first
to accrued interest and then to principal. After each payment interest will continue to accrue on
the remaining principal balance, at the rate of 10.5 percent. In addition, please note that
Medicare rules require that payment be either received in our office by 03/25/2015 or use the
United States Postal Service Postmark by that date for the payment to be considered timely. A
metered mail postmark received in our office after 03/28/2015 will cause an additional month's
interest to be assessed on the debt.
Medicaid Offset:
if this matter is not resolved, CMS may instruct the Medicaid State Agency to withhold the
Federal share of any Medicaid payments that may be due you or related facilities until the full
amount owed Medicare is recouped, Title 42 CFR, Section 447.30(g). These recoveries will be
in addition to any recoupments from other Medicare funds due you until the full amount owed
to Medicare is recovered.
If you wish to appeal this decision:
---ityou disagree-with this overpayment-decision,you-may-file-an-appeal:An-appeal-is-a-review -- — ---
performed by people independent of those who have reviewed your claim so far. The first level
of appeal is called a redetermination. You must file your request for a redetermination within
120 days from the date of this letter. However, if you wish to avoid recoupment from
occurring, you need to file your request for redetermination within 30 days from the
date of this letter as described above. Unless you show us otherwise, we assume you
received this letter 5 days after the date of this letter. Please send your request for
redetermination to:
Wisconsin Physicians Service Ins. Corp. - 935 APPEALS
REDETERMINATION
P.O. Box 8833
Appeals
Marion, IL 62959
Page 5
Date : 02/24/2015
Letter Number : 15335081
If you have filed a bankruptcy petition:
If you have filed a bankruptcy petition or are involved in a bankruptcy, proceeding,Medicare
financial obligations will be resolved in accordance with the applicable bankruptcy process.
Accordingly, we request that you immediately notify us about this bankruptcy so that we may
coordinate with both the Centers for Medicare & Medicaid Services and the Department of
Justice so as to assure that we handle your situation properly. If possible, when notifying us
about the bankruptcy please include the name the bankruptcy is filed under and the district
where the bankruptcy is filed.
Should-TOO Have any questiurts;-please-contact-your overpayment-con'sultant-at-the-followin g:
Provider- Part B: 866-234-7331
Part B Immediate Recoupment- Fax: 618-998-5283
Part B Extended Repayment Request: 866-234-7331
We look forward to hearing from you shortly.
Sincerely,
Medicare Part B
Recovery Unit
Enclosure: How This Overpayment Was Determined
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Invoice Number: 224815040700020
Claim No. Beneficiary Name HIC No. Service Date Service Date Amount Paid Date Provider No.
From To Overjpaid
221814183380650 LULA M MASTERS 405282690A 06/29/2014 06/29/2014 $274.78 07/16/2014 1154325579
I
Reason for Overpayment: Based on Medic-are Policy, services within a Skilled Nursing Facility period are subject to consolidated billing and
should not be paid separately. Our records)indicate that this claim is subject to Skilled Nursing Facility consolidated billing. Therefore,
payment was made to you in error.
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Prescribed by State Board of Accounts ACCOUNTS PAYABLE VOUCHER City Form No.201(Rev.1995)
CITY OF CARMEL
An invoice or bill to be properly itemized must show: kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours,.rate per hour,number of units, price per unit, etc.
Payee
Purchase Order No. -
Terms
Date Due
Invoice Invoice Description Amount
Date Number (or note attached invoice(s) or bill(s))
Total
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same in accordance
with IC 5-11-10-1.6.
, 20-
Clerk-Treasurer
20Clerk-Treasurer
VOUCHER NO. WARRANT NO.
V.�•�� ����-_cam ��� �\�\ � ALLOWED 20
IN SUM OF $
ON ACCOUNT OF APPROPRIATION FOR
Vzza
Board Members
PO# INVOICE NO. ACCT#!TITLE AMOUNT
DEPT.
# I hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
aR 5 X015
20
Signature
Title
Cost distribution ledger classification if
claim paid motor vehicle highway fund