SUMMARY OF THE OVERPAYMENT COLLECTION PROCESS When Medicare identifies an overpayment of $25 or more, your servicing Medicare Administrative Contractor (MAC) initiates the overpayment recovery process by sending an initial demand letter requesting repayment.
Full Answer
What are Medicare overpayments?
Medicare Overpayments Overpayments are Medicare funds that you or a beneficiary has received in excess of the amount allowed payable under the Medicare statute and regulations.
How do I get a refund for Medicare overpayments?
Although Medicare may have not notified the supplier of this overpayment, a voluntary refund must be submitted. To ensure proper recording and timely processing, submit your voluntary refund along with a check using the applicable completed “MSP Overpayment Refund Form” or “Non-MSP Voluntary Checks Refund Form” option from the Forms page.
How long do you have to report Medicare overpayments?
The Centers for Medicare & Medicaid Services (CMS) has published a final rule that requires Medicare Parts A and B health care providers and suppliers to report and return overpayments by the later of the date that is 60 days after the date an overpayment was identified, or the due date of any corresponding cost report, if applicable.
What happens after an overpayment is made?
Once a determination of an overpayment has been made, the amount of the overpayment is a debt owed to the United States Government, via Novitas Solutions, as one of its Medicare contractors. Note: If you have questions related to the overpayment process, please contact our Customer Service Center ( JH) ( JL)
How do I get a refund from Medicare overpayment?
Submit a check with the Part A Voluntary Refund Form. When the claim(s) is adjusted, Medicare will apply the monies to the overpayment. Option 2: Submit the Part A Voluntary Refund Form without a check and when the claim(s) are adjusted, NGS will create an account receivable and generate a demand letter to you.
What should you do if Medicare overpays you for patient treatment?
If Medicare Finds the Overpayment You can reply using the Immediate Recoupment Request Form, request immediate recoupment via the eRefunds or Overpayment Claim Adjustment (OCA) features in the WPS-GHA portal, or wait for Medicare to implement their standard recoupment process.
How do I recoup my Medicare payments?
When Medicare identifies an overpayment, the amount becomes a debt you owe the federal government. Federal law requires we recover all identified overpayments. When you get an overpayment of $25 or more, your MAC initiates overpayment recovery by sending a demand letter requesting repayment.
When Should Medicare overpayments be returned?
60 daysSection 1128J(d) of the Act provides that an overpayment must be reported and returned by the later of: (i) the date which is 60 days after the date on which the overpayment was identified; or (ii) the date any corresponding cost report is due, if applicable.
How can overpayment of claims be managed?
If the insurance company overpays:Contact the insurance company. ... Ask the insurer to explain the payment when they request a refund. ... If there was an overpayment, ask the insurer to reprocess the claim and send a formal request for the overpayment.
How do you handle overpayments patients payers and paybacks?
If the payer confirms that they did make an overpayment, they should reprocess the claim to show correct payment and send a request for the provider to return the overpayment. Sometimes the payer will just ask the provider over the phone to return the overpayment.
How many years back can Medicare recoup payments?
3 calendar yearsFor Medicare overpayments, the federal government and its carriers and intermediaries have 3 calendar years from the date of issuance of payment to recoup overpayment. This statute of limitations begins to run from the date the reimbursement payment was made, not the date the service was actually performed.
What is a Medicare offset?
Offset causes withholding of overpayment amounts on future Medicare payments. This is done in one of two ways: Contractor initiated when the money is not returned within the appropriate time frame after the initial notice of overpayment (see below) Provider requests immediate recoupment.
What is Medicare Secondary Payer recovery process?
Note: The Medicare Secondary Payer Recovery Portal (MSPRP) is a web-based tool designed to assist in the resolution of Liability Insurance, No-Fault Insurance, and Workers' Compensation Medicare recovery cases.
What does overpayment recovery mean?
Overpayments can be recovered by sending back the incorrect paycheck, setting up an overpayment on the Additional Pay page or allowing the automatic retro process to recover the overpaid amount.
What does recoupment mean in medical billing?
A: A recoupment is a request for refund when we overpay an account. Some of the most common reasons for a recoupment are: We are not aware of a patient's other health insurance coverage.
If You Find the Overpayment
If you or your staff detects an overpayment from Medicare, you can report it either electronically, through the eRefunds or Overpayment Claim Adjustment (OCA) features in the WPS-GHA portal, or by mail, using the Overpayment Notification/Refund Form.
If Medicare Finds the Overpayment
If your MAC identifies the overpayment (which they do for amounts over $25), they will initiate overpayment recovery by sending a demand letter requesting repayment.
How long does it take for Medicare to report overpayments?
The Centers for Medicare & Medicaid Services (CMS) has published a final rule that requires Medicare Parts A and B health care providers and suppliers to report and return overpayments by the later of the date that is 60 days after the date an overpayment was identified, or the due date of any corresponding cost report, if applicable.
When is an overpayment identified?
This final rule states that a person has identified an overpayment when the person has or should have, through the exercise of reasonable diligence, determined that the person has received an overpayment and quantified the amount of the overpayment.
How long do you have to report Medicare overpayments?
If you find an overpayment, don’t expect to keep it. That’s because physicians must report and repay Medicare overpayments within 60 days of identifying them, according to a final rule that took effect March 14, 2016. This includes overpayments identified within six years of when the overpayment is received.
What is an overpayment?
According to the agency, an overpayment occurs when an individual “has or should have, through the exercise of reasonable diligence, determined that [he or she] has received an overpayment and quantified the amount of the overpayment.” For example, an overpayment could occur due to a duplicate bill, an EMR glitch, improper modifier use, upcoding, or a variety of other reasons.
When was the final rule for Medicare Part A and Part B issued?
Medicare Parts C and D Plans and Prescription Drug Plan sponsors are subject to a separate final rule that was issued on May 23, 2014. CMS has not published a final rule to address Medicaid requirements.
What happens if you fail to comply with the False Claims Act?
Failure to comply with this rule could result in liability under the False Claims Act as well as monetary penalties and exclusion from federal healthcare programs. Be on the lookout for overpayments, and take proactive steps to ensure compliant documentation and coding.
What is overpayment in Medicare?
Clarification of “overpayment” – Broadly defined it includes the receipt or retention of any Medicare payment in which a provider is not entitled including erroneous payments issued by its Medicare contractor.
What happens if you overpay Medicare?
When a Medicare overpayment occurs, it must be reported and paid back. Failing to report or refund a Medicare overpayment is fraud which can result in added fines, penalties, and ineligibility to participate in the Medicare program.
What is Medicare Integrity Program?
The Medicare Integrity Program defines an overpayment as funds a provider has received in excess of amounts due and payable. There are many ways that overpayments can occur, coding errors, duplicate claims, and services not rendered are some of the most common.
How long does Medicare have to refund overpayments?
It is the responsibility of the provider to voluntarily refund an overpayment in a timely manner. Health care providers have 60 days after the overpayment is identified to settle the score. Those who do comply are subject to accruing annual interest rates and penalties. However, Medicare’s Part A and Part B overpayments are not treated equally. They are managed in different ways:
What is CMS in Medicare?
The Centers for Medicare & Medicaid Services (CMS) operates under the guidelines of the Affordable Care Act (ACA) to support compliance with applicable statutes, promote quality care, and help to protect Medicare Trust Funds against false payments. When a Medicare overpayment occurs, it must be reported and paid back. Failing to report or refund a Medicare overpayment is fraud which can result in added fines, penalties, and ineligibility to participate in the Medicare program.
How long does it take to repay Medicare overpayments?
It details a provider’s responsibility to repay overpayments within the 60 days of identifying it. Additionally, it outlines the consequences. Under the False Claims Act failure to submit a refund will result in a stiffer liability—up to three times the original amount and a mandatory penalty up to $11,000 per claim. The final rule provides both clarity and consistency in reporting and returning self-identified Medicare Part A and B overpayments. It addresses the following key issues:
What is the penalty for not submitting a Medicare refund?
Under the False Claims Act failure to submit a refund will result in a stiffer liability—up to three times the original amount and a mandatory penalty up to $11,000 per claim. The final rule provides both clarity and consistency in reporting and returning self-identified Medicare Part A and B overpayments.
What Happens if We Exceed the 60 Day Requirement?
In fact, the government is so focused on these issues that if such deadline for reporting and returning the overpayment is not met, the overpayment becomes and obligation. When Medicare overpayments become an obligation, the False Claims Act is implicated which allows for civil penalties up to $11,000 plus three times the amount of the government’s damages if the person knowingly conceals or avoids an obligation to pay. Knowingly includes a person with actual knowledge of the overpayment, a person who acts in reckless disregard, or a person that is acting deliberately with ignorance.
Do providers have to refund overpayments?
All providers whether it be a hospital, physician, nurse practitioner, physical therapist, or another healthcare professional always have an obligation to refund any overpayments received from Federal healthcare programs. Overpayments in general can occur in various ways. For example, a provider could have provided professional services when their license lapsed. Or, another example could be that incorrect coding occurred resulting in overpayments to the provider or the facility. In any event, those payments need to be refunded. In this post we will discuss some of the common issues and questions that arise related to overpayments.
Is Medicare overpayment a liability?
Medicare overpayments can occur in many situations which is why this issue alone presents significant liability for all organizations. To limit such risks, organizations should focus on having a compliance program that seeks out these issues. As stated earlier, the knowingly requirement creates risk for organizations that simply disregard the fact that a Medicare overpayment has occurred. Therefore, organizations should focus on having an investigative team that focuses on areas such as these. For more information related to the risks of Medicare overpayments, review the settlement with the Carondolet Health System in Arizona.
Who is the contractor for Medicare overpayment?
Once a determination of an overpayment has been made, the amount of the overpayment is a debt owed to the United States Government, via Novitas Solutions , as one of its Medicare contractors.
What happens when an overpayment is identified?
When an overpayment is identified a claim adjustment will occur. This will create a receivable account which will issue a demand letter requesting repayment.
What is extended repayment schedule?
Extended Repayment Schedule is an option of returning overpaid money to Novitas when you need extra time to repay the full amount of the overpayment.
What are some examples of overpayments?
Examples of overpayments where you could be liable include, but are not limited to, the following: Payment exceeds the reasonable charge for the service. Duplicate payments of the same service (s) Incorrect provider payee. Incorrect claim assignment resulting in incorrect payee.
Who approves accelerated payments?
Accelerated payments shall be approved by Novitas and the appropriate CMS regional office . The regional office will review each request for an accelerated payment to ensure that the provisions are being correctly and consistently applied.
What to do if you disagree with a refund request?
If you disagree with a refund request, you may choose to appeal the notice of overpayment. An appeal rights statement will be included in the initial refund letter.
What changes to beneficiary eligibility as maintained by Social Security Administration?
Changes to beneficiary's eligibility as maintained by Social Security Administration (e.g. date of death, cancelled policy, election of a Managed Care Plan)
How much can a DME MAC refund?
DME MACs will accept refunds of less than $25. A supplier must submit specific documentation to support the extended repayment plan request.
Can a supplier owe Medicare money?
Many situations may cause a supplier to owe Medicare money on previously paid claims.