SCGhealth Blog

The Long(er) Arm Of The Law: New Medicare Overpayments Rule To Go Into Effect

Monday, February 15, 2016

By Ben Regalado.

Nearly four years after it was first proposed, the Centers for Medicare & Medicaid Services (CMS) recently finalized a regulation requiring providers to report overpayments going back up to six years. The rule will be effective March 12, 2016.

Photo credit: GraphicStock © 2016.

While industry leaders see this six year look-back period as too long - it is three times longer than what Medicare routinely has told its contractors it could open up claims - it is a step down from the originally proposed of 10 years.

For practices with solid revenue cycle management and compliance programs, this should not be an issue. However, here are some steps you can take to assure you are on the right path.

RCM Capture
Your revenue cycle processes should be as strong on tracking and taking quick action on overpayments as it is on underpayments.

For practice leaders, this means always separating credit balances when reviewing your aggregate accounts receivable reports. Including them not only masks the true volume of what you are owed and how productive your collection efforts really are, but takes the spotlight off this critical area.

Be Proactive
Some practices believe it is more prudent to wait until the insurance company or patient ask for the money before returning it. This is a high risk proposition, especially for Medicare.

The Affordable Care Act requires overpayments be returned within 60 days of being identified. Failure to do so could result in extensive financial penalties under the False Claims Act, or even exclusion from the government programs. This exclusion is not just for physicians, but can extend to anyone from building managers to practice administrators, a career limiting move to be sure!

By the way, not looking for errors does not let you off the hook. In the final rule, CMS actually removed the words "deliberate ignorance" and "willful disregard", choosing instead to take a broader, more proactive tone: "CMS expects providers to maintain compliance plans as part of a "reasonable diligence" effort."

Check your record retention policy, especially if you have migrated among various practice management systems. Where are payment (such as explanation of benefits) records stored, physically or electronically, and are you able to access them in a timely fashion?

On the bright side, the rule supposedly makes it less burdensome to report and return overpayments. In addition, if for some reasons you do not detect and return an overpayment on your own, the Medicare Leaning Network has outlined several steps from immediate recoupment to appeals that your Medicare Administrative Contractor and you should follow in the event an request for repayment is made.

Six years is a long time; perhaps longer than your lifespan in the position. So don’t push it to the next practice sheriff. Set yourself, and your current practice, up for success now.

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