On February 12, 2016, the Centers for Medicare & Medicaid Services (CMS) published its Final Rule (the “Final Rule”) obligating Medicare providers and suppliers under Parts A and B to report and return Medicare overpayments within 60 days of the identification of such overpayments. The release of the Final Rule marks a significant development for healthcare providers as CMS finally provides some clarity on the obligation to report and return identified overpayments.
The Final Rule clarifies and further defines for Medicare Part A and B providers and suppliers that in order for an overpayment to be deemed to have been “identified,” a provider must have or should have exercised “reasonable diligence” to determine if an overpayment occurred. Once a provider or supplier receives “credible information,” determined on a fact-basis, of a potential overpayment, the provider is obligated to conduct “reasonable diligence” to investigate the claims. The 60-day rule applies only to overpayments identified within six years after the overpayments were received.
In the event that a provider or supplier is unclear as to whether an overpayment exists, it may seek clarification through the appeal process, provided however, that the provider is not appealing self-identified overpayments as a means to circumvent its obligations under the Final Rule. A decision made by a Medicare Administrative Contractor (MAC) or a claim denial demand from a Recovery Audit Contractor (RAC) to recoup monies from a provider, may still be appealed through the Medicare Appeals Process.
Providers should be advised that any provider or supplier who fails to report and return overpayments beyond the 60-day period risks potential liability under the False Claims Act. As such, providers would find it prudent to act promptly to investigate any credible information of a potential overpayment.
If you have questions about the implications of the Final Rule for Medicare Parts A and B providers, or require assistance with a Medicare appeal related to alleged overpayments, contact Frier Levitt today.
