C
Definition
The retroactive withdrawal of money previously paid to a provider by a payer (Broker/State) after an audit discovers errors, fraud, or lack of documentation.
Overview
Why it Matters
A provider can be paid for a year, think they are profitable, and then lose $50,000 in one day due to a clawback for missing signatures.
How it Works
The payer sends a letter demanding repayment. They usually just deduct it from future checks.
Code Comparison
Comparison: Clawback vs. Denial
Denial: You never got the money.
Clawback: You got the money, spent it, and now have to give it back.
Common Questions
- Record Retention: Failing to keep trip logs for the required 5-7 years, leaving you defenseless against a clawback.
- Self-audit 5% of your claims monthly to catch errors before the payer does.
Sources
CMS - Overpayment and Recoupment