What is a healthcare overpayment demand?
It is a payer’s request to return amounts the payer says were not payable under an identified contract, policy, program rule or claim requirement. The letter may follow a desk review, documentation request, SIU review, program-integrity audit or post-payment audit. The stated amount should be recorded as asserted until its components and sources are reconciled.
Reconcile the demand in layers
Letter total
The exact figure stated in the current demand, with the letter date and version.
Claim-file total
The billed and paid amounts that can be reproduced from the supplied claim rows.
Finding total
Amounts tied to each documentation, enrollment, coding or authorization category.
Recovery activity
Refunds, recoupments, offsets and corrected claims that may affect the remaining balance.
Questions the record should answer
- Does every demanded dollar map to an identified claim and payment?
- Are the date-of-service and payment periods the same?
- Are any claim lines duplicated across worksheets or issue categories?
- Does a percentage describe claim count, paid dollars or an extrapolation?
- Were amounts already refunded, voided, corrected or offset?
- Does the payer distinguish sampled dollars from the broader asserted balance?
Do not confuse error rate with financial exposure
A claim-count error rate does not automatically equal the percentage of paid dollars at issue. A sample with many low-dollar findings can produce a high count rate and a different paid-dollar rate. Heaude preserves both calculations and labels the payer’s broader figure separately so counsel can review the methodology without inheriting an unsupported calculation.