Medicare and Medicaid Audit Overpayments: Challenging Statistical Sampling and Extrapolation

Recording of a 90-minute CLE webinar with Q&A

This program is included with the Strafford CLE Pass. Click for more information.
This program is included with the Strafford All-Access Pass. Click for more information.

Conducted on Tuesday, September 22, 2020

Recorded event now available

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This CLE course will provide insight to counsel for Medicare and Medicaid providers on how to effectively evaluate and potentially challenge overpayment sampling and extrapolations in provider audits.


Medicare and individual state Medicaid agencies are using statistical sampling and extrapolation to determine overpayments in their audits and investigations. Centers for Medicare & Medicaid Services (“CMS”) revised its Medicare Program Integrity Manual (MPIM) provisions on sampling and extrapolation which became effective in 2019. The MPIM provides additional information regarding several aspects of the sampling and extrapolation process that providers should consider when challenging extrapolated reviews by payors.

A sample of claims is audited and the results of that audit are extrapolated to the claims universe, resulting in substantial repayment demands on providers. When facing an alleged overpayment, Medicare and Medicaid providers generally have the burden of demonstrating that the reimbursement they received was proper. If the Medicare or state Medicaid agency uses statistical sampling and extrapolation to establish the overpayment, it is the provider's burden generally to present sufficient evidence to refute the sampling and the extrapolation process. If the provider is successful, the extrapolated repayment amount will be removed from the case, leaving only the sample disallowance findings and corresponding repayment to be challenged. This is typically much less of a financial burden to the provider than the extrapolated result.

To challenge these state determinations of overpayment, Medicaid providers can look to Medicare rulings and cases for persuasive, but not binding, guidance. The rules of statistics need to be observed for an extrapolated result to be valid. It is critical for Medicare and Medicaid providers and their counsel to understand proper statistical sampling and extrapolation methods, and to know how to challenge questionable processes to minimize potential repayment obligations.

Listen as our authoritative panel examines how Medicare and Medicaid programs are using statistical sampling and extrapolation to recover alleged Medicare and Medicaid overpayments. The panel will discuss how counsel for health care providers can effectively challenge the sampling and extrapolation methodology and the alleged resulting overpayment.



  1. How the Medicare program and state Medicaid programs are using statistical sampling and extrapolation
    1. Sampling methodology
    2. Requirements of a probability sample
  2. Challenging sampling and extrapolation methodologies
    1. Attacking statistical validity
    2. Detecting flaws in the audit method
    3. Evidence rebutting results
    4. Leveraging guidance from Medicare cases and the MPIM


The panel will review these and other key issues:

  • Primary considerations for Medicare and Medicaid providers in working with counsel to challenge such overpayments
  • Proactive steps needed to mount the challenge
  • Data required to properly evaluate a payor’s statistical sampling and extrapolation
  • Critical need for a statistical sampling and extrapolation expert on the case


Maykuth, Patricia
Dr. Patricia L. Maykuth, Ph.D

Research Design Associates

Dr. Maykuth is a statistical expert with particular skill in experimental design, statistical sampling and...  |  Read More

Ross, David
David R. Ross

Senior Shareholder
O’Connell and Aronowitz

Mr. Ross concentrates his practice on Medicaid, Medicare and private insurance audits & investigations, and health...  |  Read More

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