A few weeks ago, we presented a webinar on the impact of the 60-day overpayment rule since its release two years ago. We had so many questions at the end of the webinar, we couldn’t get to all of them. So, we thought it would be a good idea to address some of them here. If you missed the webinar, Revisiting the 60-Day Rule, you can watch it on-demand.
QUESTION
Can you provide a source document for the "single overpaid claim" expectation for probe?
ANSWER
Yes. For a little background, recall that during the webinar I stated the final rule sets an expectation that if a single overpaid claim was identified, there is an expectation to determine if the problem that created that single overpayment applied to a greater universe of claims. In response to commenters’ concerns about needing to do additional due diligence after finding a single, overpaid claim, CMS responded, in part, in the final rule that:
“Providers and suppliers are obligated to conduct audits that accurately quantify the overpayment. After finding a single overpaid claim, we believe it is appropriate to inquire further to determine whether there are more overpayments on the same issue before reporting and returning the single overpaid claim.”
This statement is just part of their response and I encourage everyone to read its full context within the final rule itself at Federal Register. Volume 81, No. 29. Friday, February 12, 2016. Page 7663.
QUESTION
Do commercial payers also follow the 6 year look back?
ANSWER
This question is representative of many other similar questions about commercial payers vs. government payers.
The final rule we discussed during the webinar specifically addresses Medicare Parts A and B. A separate final rule was published for Medicare Parts C and D.
The foundation for these rules was the Affordable Care Act. I am not an attorney, though I have discussed this with many attorneys who recommend these principles be followed for all government payors. Check with legal counsel for specifics about your organization and situation. We also have legal consultants who work for Healthicity if you need assistance.
Most commercial payers have contracts with providers. Typically terms for returning overpayments are subject to the terms of the contract with that payor and/or state law. I’ve blogged previously about state false claims acts for which you should become familiar for the states you operate in. Some state false claims acts address commercial payers. Again, if assistance is need please reach out to me at cj.wolf@healthicity.com
QUESTION
So if you are appealing the claim because you do not believe the overpayment was correct - do you need to worry about the 60 day rule?
ANSWER
The above question, along with similar questions were posed by commenters in the Final Rule. The response from CMS was:
“The provisions of this final rule establish that a person has the responsibility to conduct an investigation in good faith and a timely manner in response to obtaining credible information of a potential overpayment and to return identified overpayments by the deadline set forth in § 401.305(b). This responsibility exists independent of the appeals process for contractors’ overpayment determinations. We believe that contractor overpayment determinations are always a credible source of information for other potential overpayments. Moreover, we recognize that in certain cases, the conduct that serves as the basis for the contractor identified overpayment may be nearly identical to conduct in some additional time period not covered by the contractor audit. If the provider appeals the contractor identified overpayment, the provider may reasonably assess that it is premature to initiate a reasonably diligent investigation into the nearly identical conduct in an additional time period until such time as the contractor identified overpayment has worked its way through the administrative appeals process.”
This statement is just part of their response and I encourage everyone to read its full context within the final rule itself at Federal Register. Volume 81, No. 29. Friday, February 12, 2016. Page 7667.
These are just a few of the unanswered questions from the webinar. If you still have questions, please feel free to email me at cj.wolf@healthicity.com
CJ Wolf
Questions or Comments?