What to do with over payments, keep it or refund it. Over Payments, keep it or refund it, thin line to cross.
Dealing with insurance payers to get pay is a stressful task , getting paid is becoming harder and harder
. The biggest questions is in regard to handling potential overpayment. regarding internal or external audits is whether or not the errors constitute a self-disclosure protocol. The short answer is, avoid this process unless you have verifiable fraudulent activity to report.
Section 1128J(d) of the Affordable Care Act created an express duty to refund and report Medicare and Medicaid overpayments “by the later of” 60 days after the overpayment was “identified” or the date the cost report is due. The Final Rule only applies to overpayments from traditional Medicare- Parts A & B.
The rule includes very specific language regarding a specific aspect of the process including the “Look-back Period” and what it means to “Identify” an overpayment. Let’s take a closer look at these:
The Final Rule sets out CMS’s decision that providers have an obligation to exercise “reasonable diligence” through “timely, good faith investigation of credible information.” (81 Fed. Reg. at 7662). CMS clarified that this means both proactive and reactive reviews of Medicare billing – merely aud
iting based on compliance hotline calls or issues raised by staff is insufficient.
An overpayment is not “identified” until the amount of the refund has been quantified. Add the 60 days for reporting plus the 6 month for timely investigation , that means an 8-month period.
The Final Rule regarding retained overpayments settled on a 6-year look-back period. The 6-year look-back is not retroactive, and will be effective March 14, 2016.
The 60-day clock does not start running until after the reasonable diligence period has concluded, which may take at most 6 months from receipt of credible information,
The following is a guidance on handling a Medicare overpayment.
Voluntary Refund Disclaimer/Medicare Overpayments Part B
Overpayments are Medicare funds that a provider or beneficiary has received in excess of the amount actually allowed payable under the Medicare statute and regulations. Once a determination of an overpayment has been made, the amount of the overpayment is a debt owed to the United States Government or its Medicare contractors.
An overpayment may be discovered in one of the following ways:
1. The beneficiary or the provider may find the payment error
2. A contractor employee may discover the overpayment during a review process
3. A medical director’s decision may result in identification of an overpayment; or
4. A claims processing department may identify an overpayment while processing subsequent claims.
Notifying Medicare of an Overpayment
If you believe that an overpayment has been made, you can notify Medicare part B by in one of the three ways listed below. Regardless of how you notify Medicare of the overpayment, you must provide the following information:
1. Provider name
2. Provider number(Tax ID, NPI and PTAN numbers)
3 Health Insurance Claim number(s)
4. Reason for overpayment
5. Amount of overpayment
6. Method of repayment
7. Copy of the primary insurance Explanation of Benefits
Unsolicited Return of Money
‘Unsolicited’ means you identified the overpayment and are voluntarily returning the money before a refund is requested. Send a business check for the specific overpayment amount, do not return the Medicare check. Complete the “Return of Monies to Medicare” form Part B (click to access form) and send the check to the appropriate address listed on the form. In order to process your payment more efficiently, a separate check should be issued for each provider that was overpaid. You will be contacted if it cannot be determined why the payment was sent or if there is missing information needed for processing. CMS defines patient name, claim number, and DOS (Date of Service) as required information to be submitted with the refunds.