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14 Mar


Earlier this year, the Rules for Reporting and Returning Medicare Overpayments was Finalized by The Centers for Medicare and Medicaid Services (“CMS”).


What you need to know

Regardless of whether you are a provider under Medicare Part A, Part B or both once you identify that you have received an overpayment you have only 60-days to report it or refund it or risk running afoul of the False Claims Act. The Final Rule also allows a non-retroactive 6-year “look back” enforcement period effective March 14, 2016 for reporting and refunding overpayments so if you received a payment prior to March 14, 2016 but identified it as an overpayment on or after March 14, 2016 the Final Rule still applies.


The Final Rule requires that providers exercise “reasonable diligence” through “timely, good faith investigation of credible information.” This means you must have in place and use a reasonable, good faith and timely process aimed at identifying overpayments. CMS has also stated in the Final Rule that the 60-day Reporting and Refund clock does not start until 1) after the “reasonable diligence” period, which can take “at most 6 months from receipt of credible information, absent extraordinary circumstances” and 2) the amount in question has been “quantified”.


This means that you cannot only rely on a “reactive” approach that responds to calls from patients or insurers, audits or notices from CMS or reports from your staff or billing or coding company. You must have a “timely and proactive” self-managed claims payment review program in place to identify overpayments and the amount then report and refund those amounts. Furthermore, your identification of an overpaid claim may not be able to stop there. An identified overpayment may trigger an investigation of other claims. The Final Rule provides examples that may trigger such further inquiry.

  • Upon review of billing records it is identified that certain services were coded incorrectly, resulting in increased reimbursement.
  • Receipt of notice of a patient’s death, which is prior to the date of service on a submitted claim.
  • Determination that services were rendered by an unlicensed or excluded individual.
  • An internal audit reveals a potential overpayment.
  • A government audit alleges an overpayment.
  • An unanticipated or unexplained increase in revenue.


What you Need to DO

You should immediately develop, document, train your staff and implement a protocol to look for and identify suspected overpayments. Consult with your coding and billing staff or contractors about promptly reporting claim coding, processing and submission errors or overpayments to you. Promptly investigate all reported or found overpayments. Promptly refund all identified overpayments. If you feel that you may have exposure to multiple overpaid claims you should consult a qualified healthcare attorney.


How To Report/Refund an Overpayment

Each Medicare Payment Contractor has a protocol for refunding payments and you should familiarize yourself with your contractor’s guidance. The Final Rule states that the 60-day time period for refunding an overpayment will be suspended if 1) the Health and Human Service (“HHS”) Office of Inspector General (“OIG”) acknowledges receipt of a submission to the OIG Self-Disclosure Protocol or 2) CMS acknowledges receipt of a submission to the CMS Voluntary Self-Referral Disclosure Protocol or 3) a person requests an extended repayment schedule.