Insurance

02/14/2018

Medicare Advantage – Clover Audit Letter

Many ANJC members have received letters from Clover, a Medicare Advantage insurance carrier, stating that files had been audited, overpayments were issued to the doctor and will be recouped.  The letter was generic and offered no details such as patient names, dates of services, reasons for the retrospective denial nor any appeal instructions.  A second page was included which contained only random sets of numbers.  It turned out these were claim numbers, but there was still no other identifying information or explanation for the denials.  The letters did contain a phone number to call for more information.  When I called this number, after pressing 0 for an operator, the following outgoing message was played: 

 “If you received a letter dated December 29^th(2017), this letter was to provide advanced notification of a routine retrospective audit to identify claims billing inaccuracies.  No recoupment or offset has been performed and no action is needed on your part at this time.  If in the future we see inaccuracies including NCCI, NCD and LCD rule violations for which payment may have been issued in error, you will receive an additional letter from us with details including cause, amount, process and appeal rights in advance of any action.” 

 Given this message, it appears the initial letters were worded incorrectly and no recoupment actions are currently underway.  However, if you have treated Clover patients please keep a sharp eye out for any follow-up letters which do give the details listed in this message.  If you receive any additional correspondence from Clover that you feel is inappropriate or do not fully understand, contact me at matt@anjc.info for assistance.