The Centers for Medicare & Medicaid Services (CMS) has issued a final rule regarding the legal requirements providers most follow if they are overpaid.
Healthcare providers and suppliers are required to notify the appropriate state or federal agency within 60 days of identifying an overpayment.
CMS made two significant changes from the proposed rule that was issued last year. First, it lessened the onus on providers to identify an overpayment. Primarily, providers or suppliers must identify overpayments if they exercise "reasonable diligence" in locating them. The proposed rule put the burden of only knowing the existence of an overpayment, or deliberately disregarding such knowledge.
The rule also cuts the proposed lookback period for overpayments from 10 years to six. "This change will reduce the burden on providers when investigating suspected overpayments," Brian P. Dunphy, an attorney with the law firm Mintz Levin, told Becker's Hospital Review.
Overpayments have always been a sticky issue in the Medicare program. CMS has long maintained that overpayments for claims have always been much larger than underpayments. At the same time, the agency has had significant issues in clawing back overpayments, with uncollectible sums running into the hundreds of millions of dollars.
Options have also been provided for repayments, such as a claims adjustment, credit balance, self-reported refund or other methods of balancing the ledger.
Healthcare providers and suppliers that don't comply with the rule could be civilly liable under the federal False Claims Act.