Case File · Audits, Appeals & FWA
An extrapolated demand, reduced to a fraction at hearing.
A UPIC's extrapolated overpayment demand, challenged at an ALJ hearing — where the extrapolation was thrown out and the amount owed cut to a fraction.
Reduced
ALJ outcome · extrapolation overturned
The challenge
A Medicare provider received a records request from a Unified Program Integrity Contractor (UPIC) covering a defined claims period. The review produced an overpayment finding, and — as is now standard — the contractor extrapolated that finding across the full universe of claims, turning a sample-level error rate into a demand many times larger than the dollars actually reviewed.
Our approach
We managed the records production end to end — assembling the responsive documentation to the contractor's own specifications so the record was complete, indexed, and defensible before it left the building. We then took the matter through the appeal levels to a hearing before an Administrative Law Judge, where we challenged the statistical sampling and extrapolation methodology directly: how the sample was drawn, whether it was valid, and whether the extrapolation could stand.
The impact
The ALJ invalidated the extrapolation. With the universe-wide projection gone, the provider's liability fell from the original extrapolated demand to only the actual overpayment on the claims genuinely in error — a fraction of where it started.