The 60 Day Rule
Understanding the Medicare Reporting and Returning of Self-Identified Overpayments
The U.S. Centers for Medicare and Medicaid Services (CMS) has issued a long awaited final rule around the statutory requirement requiring Medicare providers to return overpayments within 60 days of the date they are identified in order to avoid liability under the False Claims Act.
Under the final rule, a provider identifies an overpayment when it determined that the person has received an overpayment and quantified the amount of the overpayment. “Actual Knowledge” is not required for the rule to be applicable”: Identified” is defined as “has, or should have through the exercise of reasonable diligence, determined that an overpayment has occurred.” Medicare believes it should take “at most” 6 months from receipt of credible information to exercise reasonable diligence and determine whether an overpayment has been received.
Examples of overpayments include:
- Accidental or intentional up-coding
- Billing for inappropriate or medically unnecessary services
- Billing for services or tests that were never performed or not supported by documentation
- Falsifying records or statements to get a claim paid or approved
- Identified systemic/operational errors
The proposed rule set a 10 year look back for overpayment totaling. The final rule reduces the lookback period to 6 years with the 60 day timer beginning on the date of identification of overpayment. After 60 days, the claim is considered a false claim and the provider is made liable for up to triple the charge plus up to $21,000 for each improper claim. In addition, providers may face the possibility of exclusions from federal health care programs.
CMS’ final rule is the clearest charge to date that healthcare providers must have an effective compliance programs in place that allows for the timely identification and refund response of inappropriate payments.
What You Can Do To Comply
Report any suspected overpayment activities to your manager. If this is not an option, contact our Compliance office ([email protected] or [email protected]) or an anonymous report can be made by calling 1-866-665-4296.
NOTE:
Any retaliation against any person who reports, in good faith, an actual or perceived violation of our Compliance program or other applicable laws, regulations or policies is strictly prohibited per University policy.
Medicare’s Fact Sheet:
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-02-11.html
Final Rule:
https://www.gpo.gov/fdsys/pkg/FR-2016-02-12/pdf/2016-02789.pdf