Medicare Compliance & Reimbursement

Like many billing compliance hazards, the 60-day overpayment rule can trip you up — big time, compliance experts warned at the recent American Society of Cataract and Refractive Surgery meeting in New Orleans.

What Is the 60-day overpayment rule again?

If your health care organization identifies an overpayment from Medicare or other federal health programs, you have 60 days to return that overpayment, the Centers for Medicare & Medicaid Services said in a rule published earlier this year.

So what’s the big deal?

Returning one overpayment is simple, but some overpayments aren’t one-time mistakes, healthcare attorney Alan Reider of Arnold & Porter told ASCRS attendees. An overpayment that stems from a systemic coding problem could be just one among many overpayments. The feds expect providers to do a retrospective lookback to make sure one overpayment isn’t part of a larger overpayment problem involving more money.

You might have more work to do.

You must perform “reasonable diligence” to identify all of your overpayments within the past six years, and once you discover them, you must issue refunds to the MAC within 60 days.

If you don’t, you could be held liable under the False Claims Act or Civil Monetary Penalties Law — and you could even find yourself excluded from the federal health care programs.

Wait, did you say FCA?

“This is a statutory regulation that’s going to create a lot of discomfort,” Reider warns. “You have to know what you’re doing. It’s a classic whistleblower issue.”

Translation: A practice that drags its feet on a suspected overpayment could find itself with a much bigger problem after 60 days — a staffer who wants to cash in on being a qui tam relator.

Don’t panic. But don’t procrastinate either.

Just because you’ve found documentation problems doesn’t necessarily mean you were overpaid, Reider reminded ASCRS attendees. You were overpaid if your practice used the incorrect code.

It’s a pain if you find an overpayment and an even bigger pain if you suspect it’s part of a pattern, but “you’ve got to keep one thing in perspective,” Reider says. “You’ve been overpaid. You’ve got to pay it back.”

Note: Read more about the overpayment rule here: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-02-11.html.