Practice Management Alert

Question: How should I handle overpayments by insurers? How fast do I have to repay? If the amount overpaid is small, do I still have to refund it?

Georgia Subscriber
Answer: Healthcare providers should have a protocol for repaying overpayments. At the very least, when end-of-the-month reports are run, a credit balance report should be included, and any overpayments by any health plan should be refunded, regardless of the amount.
 
Refunding of overpayments is addressed in both the Office of Inspector General's compliance guidance for physicians and its guidance for third-party billing companies. Healthcare providers have a legal obligation to repay discovered overpayments. Given the complexity of Medicare regulations and the large number of claims a provider submits, overpayments are probably inevitable.
 
A variety of laws obligates healthcare providers to return overpayments to the payer, including laws not necessarily drafted with the healthcare industry in mind. Social Security law details criminal penalties for acts involving Medicare or state healthcare programs (42 USC 1320a-7b), and it applies to providers billing Medicare or a state health program, such as Medicaid. Although this law does not specifically state that a provider has an obligation to refund overpayments, it does prohibit concealing or failing to disclose submission of claims for reimbursement that were not owed to the provider "with an intent fraudulently to secure such benefit or payment either in a greater amount or quantity that is due."
 
The federal crime and criminal procedure law covers the theft or embezzlement in connection with healthcare (18 USC 669) and applies to providers receiving funds from any healthcare benefit plan. The law imposes criminal penalties of up to 10 years in prison on whoever "without authority converts to the use of any person other than the rightful owner, or intentionally misapplies any of the moneys, funds ... of a healthcare benefit program." Although the provider may not be liable for the receipt of the funds, that does not negate the provider's obligation to return an overpayment once it has been identified.
 
After discovering an overpayment, a practice may be tempted to delay making a refund until the carrier requests it. Doing that puts you at risk of noncompliance because OIG prefers that practices conduct regular reviews of their credit balances to find overpayments and refund them.
 
Before refunding any money, make sure the balance isn't a payment-posting mistake. If the overpayment is legitimate, determine what occurred and develop a process to avoid it in the future. Before making the refund to the insurer, contact the company to learn its policies about such credit balances. Carriers differ in how they handle refunds. When you send the insurer a refund check, make sure you include a letter explaining the [...]