Anesthesia Billing and Collections: CMS Proposes 10 Year Look-Back Period in Medicare, Medicaid Overpayment Rule
Author : Doc Clemens
CMS Proposes 10 Year Look-Back Period in Medicare, Medicaid Overpayment Rule
On February 14, CMS issued a proposed rule that addresses providers’ obligations to report and return Medicare and Medicaid overpayments. Based on a provision in the Affordable Care Act, the proposed rule requires providers and suppliers to report and return self-identified overpayments either within 60 days of the incorrect payment being identified or on the date when a corresponding cost report is due – whichever is later. Failure to report and return the overpayment within the appropriate time frame could be a violation of the False Claims Act and providers could be subjected to civil monetary penalties or exclusion from participating in federal health care programs. Overpayments include duplicate payments, payments to the wrong person, payments for excluded or medically unnecessary services and payments for services that are not covered by Medicare or Medicaid.
The proposed rule would impose an obligation on providers and suppliers to investigate possible violations. As an example, the rule indicated that a provider that had a significant increase in revenue for no apparent reason would be obligated to investigate and that failure to do so would be acting in reckless disregard or deliberate ignorance. CMS also is proposing a 10 year look-back period for overpayments. The look-back period would be based on the date of the initial payment. This proposal differs significantly from current rules, which provide for a claim to be reopened within one year for any reason and within four years of payment if “good cause” can be shown.