EOB with Takebacks (OSCAR)

[ajf_92@icloud.com]

Does anyone understand the terminology that Oscar used in the EOB when doing takebacks.
I am seeing the terms refund request, offset, overpayment.
While also seeing claims being taken back multiple times, but now I am starting to think that they are explaining the process of the take back.
I am just not understanding it 100% yet completely.
Please help if anyone has any experience or knowledge about this process.

 

[manny23]

Hi,

Take back process is slightly technical in nature and have broader aspects when it comes to Center for Medicare & Medicaid, and could be associated with improper payment error testing and/or conditional payment case and/or MN questionable and/or new material evidence (NME) gets available in centralized database post adjudication and/or FI, VMS system glitches. This is sometimes replicate with recoup process, but recoupment can be done by end user knowingly incorrect submission of any data while take back is initiated by payer i.e payer initiated PI level.

Reasons could vary depending on payers like commercials may have their own criteria but majorly commercials MA may have similar traits.

Thanks,
Manny
(Medicare institutional billing RTP specialist & investigator, CMS A/B expert, FI proficient, CPC)