Do you owe Medicare money?

Is it possible that you have, in the past six years, been overpaid by Medicare for your services? If the answer is “yes,” then read on.

The final rule, summarized below, implements a provision in the Affordable Care Act (ACA) which requires providers to identify and return overpayments within 60 days. Violators may be subject to penalties under the False Claims or the Civil Monetary Penalties Law as well as possible exclusion from participation in federal health care programs. The new rule is enforceable by the government and whistleblowers, and makes it easier to penalize providers for failures to repay voluntarily.

For more information, read a brief summary of the rule below. This should not be interpreted as legal advice. If you think the overpayment rule may apply to you and your practice, we recommend you contact a knowledgeable health care attorney. If you do not have a health care attorney, the Advocacy Council may be able to help you find one.

  • An overpayment is any Medicare payment received or retained by the group to which it is not entitled, regardless of the cause.
  • The law requires the overpayment be repaid within 60 days of when it is “identified.”
  • Although the 60-day overpayment rule has been in effect since 2010, there were no implementing regulations until now. Consequently, there was no clarity as to what it meant to “identify” an overpayment and when the 60-day clock started. The final rule states the 60-day repayment clock will begin to run only after the provider has identified the overpayment and quantified the amount - so long as the provider exercises reasonable diligence.
  • Reasonable diligence includes both proactive compliance activities designed to detect overpayments and reactive investigations designed to quantify overpayments in response to credible information.
  • In nearly all circumstances, investigation and repayment should be completed within eight months.
  • Failure to exercise reasonable diligence causes the 60-day repayment clock to revert back to the date the provider received credible information of the overpayment.
  • The look back period is six years from receipt of payment.
  • In the case of a contractor audit, where the provider appeals the findings, ordinarily the provider may complete the administrative appeals process before investigating other possible overpayments on the same issue.

Read more about the final rule. If you have additional questions, we’re here to provide further information on the final rule although, as noted above, we cannot provide legal advice.

Advocacy Issue: 
Billing, Coding & Payments