Federal Government Sets Clock For Return of Medicare Overpayments: Be Late At Your Own Peril
In February, the Centers for Medicare and Medicaid Services issued final regulations on the reporting and returning of Medicare Part A and Part B overpayments.
The federal False Claims Act renders illegal the making of fraudulent claims for payment to the United States government. Penalties are three times the amount of the improper payment plus up to $11,000 per claim.
The law also prohibits a “reverse false claim." Essentially, it makes it a false claim to conceal or to knowingly and improperly avoid or decrease an obligation to pay or transmit money or property to the federal government.
Due to a provision in the Affordable Care Act, overpaid Medicare (as well as Medicaid) claims must be paid back to the United States government within 60 days of the “date on which the overpayment was identified.” There is no requirement of a specific intent to defraud.
In other words, the failure to repay Medicare claims within 60 days of the “date on which the overpayment was identified” makes each of those claims a “reverse false claim” subject to the False Claim’s Act’s draconian penalties. But, the Affordable Care Act did not define what constitutes “identification.” Thus, it was impossible to know exactly what triggers the start of the 60-day clock for repayment.
Fortunately for providers, the new, final regulations, which are effective on March 14, 2016, provide clarity.
The 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.”
In other words, although there is a requirement of reasonable diligence, “identification” doesn't occur (and, therefore, the 60-day time clock does not begin to run) until the provider both determines that it received an overpayment and quantifies the overpayment.
Note also that the reasonable diligence requirement means that you cannot ignore evidence that there may have been an overpayment. It still behooves all providers to have an active billing compliance program to check for potential overpayments and to then follow up quickly and diligently in the event that there’s even a suspicion of an actual overpayment.
Note that the new regulations apply only to Medicare Part A and Part B overpayments, not to other parts of Medicare and not to Medicaid. In those other areas there is no guidance and, accordingly, additional danger that a billing mistake can be recast as a reverse false claim.
The new regs made other important changes to the rules governing the return of overpayments. I’ll address them in detail in a planned webinar. In the meantime, let me know if you have any questions about the regulations as they pertain to you or your group.
Understanding The OIG Advisory Opinion Process - Tuesday, April 12, 2016.
A violation of the Federal Anti-Kickback Statute can lead to jail, fines, and Civil Monetary Penalties. Learn the strategies and secrets of using OIG Advisory Opinions to help shape your dealings with facilities, physicians, and other providers.
Click here for more information and registration.
Wisdom. Applied. 86 - You're Dead. Now what? Succession and Medical Group Governance
Have you heard the one about the man who doesn’t walk into a bar?
Medical groups generally address governance from the aspect of current control. That’s the issue of who’s in charge. But there’s another aspect of group governance.
First impressions matter, and this is more than simply a social rule.
A few years ago, a new notebook computer that we had ordered arrived at the office. We have other computers, from Macs and other Apple products to a number of PCs that we use for various functions.
In ordering the new notebook computer, my office administrator evaluated what it would be used for and chose a Dell over a Mac because of the programs it must run. Because of our good experience with Mac products, especially their design and user interface, we knew there’d be a trade-off — but here’s the point about first impressions:
As I began to open the lid of the new Dell notebook for the first time — just an inch or two open — I could see that the stickers placed on the lower right hand of the computer’s face were put on crooked. What do you think my immediate impression was of the Dell? Yes, that it’s sloppily and cheaply made. My overall impression was focused through the initial lens.
What first impressions are you and your group giving to patients, referring physicians and hospital administrators?
What can your group do to construct, manage and exploit the power of first impressions?
Have you tied the creation of first impressions together with the provisions of your partnership/shareholders agreement, employment agreements and subcontracts, and the group’s compensation plan? Why not? Get started now!
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Mark F. Weiss
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Having fallen for the fallacy that there’s profit in market share, hospitals have gorged on acquisitions and on employment and alignment of physicians. Many physicians have been willing participants through practice sales and in the belief that there’s safety in hospital employment. But it’s becoming evident that physician employment leads to losses and that integrated care delivers neither better care nor lower costs. And now, technology is about to moot many of the reasons for a hospital’s existence. How can your practice survive and even thrive in the post-hospital world?
The Impending Death of Hospitals is available for purchase in hard copy or in Kindle format on Amazon or you can download a complimentary PDF version here.
Today’s medical groups must confront multiple challenges: The impact of Obamacare. Increasing commoditization. More competition, not just from other physicians and medical professionals, but also from hospitals, investor-owned groups, and disruptive ventures. Yet at the same time, the future of healthcare offers medical groups tremendous opportunity.
This small book is a collection of essays, of thoughts as thinking tools for your success. Read. Think. Succeed. Repeat.
Some days, it seems as if everyone, from anesthesia groups to vascular surgery practices, is talking about selling their practice to a larger group, to private equity investors, or to a hospital.
The reality is that some practices can be sold, some can never be sold, and some have nothing to sell.
The reality also is that there are a number of strategic alternatives to a practice sale.
A perfect storm of factors is accelerating the market for hospital-based medical group mergers and acquisitions.
The healthcare market is changing rapidly, bringing new sets of problems.
How can you find a solution, how can you engage in the right development of strategy, and how can you to plan your, or your group’s, future without tools to help clarify your thinking?
Directions is a collection of thoughts as thinking tools, each intended to instruct, inform, and even more so, cause you to give pause to instruct and inform yourself.
If you're an independent learner or need a refresher on a current topic, click here to find out about our growing list of Knowledge Products.
Recent Interviews and Published Articles
Mark's article Impending Death of Hospitals: Will Your Anesthesia Practice Survive? was published in the winter 2016 volume of Communique. Read or download here.
Mark was quoted in the article Practice Patterns Change While Outcomes Remain Steady Among Older Anesthesiologists, published in the December 2015 issue of Anesthesiology News. Read or download here.
Mark's article Anesthesia Group Mergers, Acquisitions and (Importantly) Alternatives was published in the summer 2015 volume of Communique. Read or download here.
Mark was quoted in the article Anesthesiology Acquisition Rate Still at Fevered Pace, published in the July 2015 issue of Anesthesiology News. Read or download here.
Mark's article Seeking Certainty In Radiology: Mergers, Acquisitions and Alternatives was published in June 2015 on Imagingbiz.com. Read or download here.
Mark's article Give Disruptive Docs the Boot was published in the April 2015 issue of Outpatient Surgery. Read or download here.
Mark's article Do You Make This Mistake Concerning Customer Value? was published in the April 2015 issue of Anesthesiology News. Read or download here.
Mark's article Do You Make This Mistake Concerning Customer Value? was published in the March 2015 issue of General Surgery News. Read or download here.
Mark's article McDonald’s and Delivering Anesthesia Group Value was published on AnesthesiologyNews.com on December 30, 2014. Read or download here.
Mark was quoted in the article Top 5 financial challenges facing physicians in 2015, published in the December 2014 issue of Medical Economics. Read or download here.
Mark was quoted in the article Top 15 challenges facing physicians in 2015, published in the December 2014 issue of Medical Economics. Read or download here.
Mark's article Bundled Billing or Bungled Billing? was published in the October 2014 issue of Pain Medicine News. Read or download here.