This week’s "Deeper Than the Headlines" post is in response to my Reverse False Claims Act webinar that I presented last Wednesday, June 19th. Thanks again to everyone who tuned in. If you missed it, we highly recommend watching because we covered a lot of great stuff. You can find answers to some of your most pressing False Claims Act questions below.
Question 1: How many years do you have to go back to find overpayments once you discover the problem and realize it was more than one patient?
Answer 1: Per the Final Rule referenced in the webinar, the look-back period for an identified overpayment is 6 years.
Question 2: Is the term "overpayment" that is being used in this webinar referring to payments issued for fraudulent claims only or for any overpayment, even for legitimate claims?
Answer 2: The cause of the overpayment is irrelevant. In other words, it includes “fraudulent” claims as well as claims where the provider was not at fault. For example, the provider may have billed everything appropriately, but if they were overpaid, at no fault of their own, they need to return the overpayment within the 60 days as well.
Question 3: Should we apply the same concerns to Medicare Replacement products (i.e., Medicare Advantage, etc.)?
Answer 3: The webinar focused on the Final Rule for Medicare Parts A and B which was published in the Federal Register on February 12, 2016. The Final Rule for Medicare Parts C and D were addressed in a separate final rule which was also published in the Federal Register, but it was published on May 23, 2014, and can be found here. Though details might differ, the general principles are the same.
Question 4: Does the 60-day rule apply to circumstances where there is no overpayment, but there is an improper payment? (i.e. less than or equal to the payment that you would had received if you submitted a correct claim?).
Answer 4: An improper payment would be considered an overpayment. From the presentation: “…overpayments are any funds that a person has received or retained under title XVIII of the Act to which the person, after applicable reconciliation, is not entitled under such title.” Your question about “improper” payments seems to meet this definition of overpayments.
Question 5: Are these overpayments only to hospitals or are there payments made to manufacturers for products or services?
Answer 5: The webinar focused on overpayments received in the context of Medicare Parts A and B. Overpayments in the context of Medicare Parts C and D are addressed in a separate Final Rule (see question previously answered).