The Centers for Medicare & Medicaid Services (CMS) published a final rule regarding the reporting and return of overpayments identified by the supplier. The overarching premise of this rule is to clarify what is expected of suppliers and to codify just how far back these overpayments must reach. The regulation does not stipulate any NEW penalties for providers that do not comply, but there are plenty of existing regulations that assess fees and penalties for erroneous billing. When a provider has knowledge of these acts and omissions, penalties can be exacerbated. The major provisions are summarized below:
- Suppliers are required to report and return an identified overpayment by the later of 60 days after the overpayment is identified OR the date any corresponding cost report is due where applicable. The rule carves out the meaning of “identified” as when the person has or should have, through the exercise of reasonable diligence, determined that they have received an overpayment and quantified the amount of the overpayment. The ruling also describes the meaning of reasonable diligence as “both proactive compliance activities conducted in good faith by qualified individuals to monitor for the receipt of overpayment and investigations conducted in good faith and in a timely manner by qualified individuals in response to obtaining credible information of a potential overpayment.”
- Suppliers are required to report and return overpayments identified within a six year lookback period. This means that overpayments identified within six years of receipt must be reported and returned.
- Suppliers may report and return overpayments using the following methods: use of an applicable claims adjustment, credit balance, self-reported refund, or another appropriate process to satisfy the obligation.
These regulations are effective as of March 14, 2016.
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