Understanding CMS’s 60 Day Refund Rule

As a feature of the Affordable Care Act “ACA”, Congress defined the process for providers to return Medicare and Medicaid overpayments. In 2012, CMS proposed the 60-day Refund Rule, as it is commonly known. This new rules requires Medicare providers and suppliers to report and return reimbursements made by mistake inside of 60 days of first identification.

Overpayments, what are they?

As indicated by CMS, an overpayment is when any funds received by a healthcare service or practitioner that are in excess of sum to be paid under Medicare’s statutes and regulations. Medicare Overpayments can be accredited to numerous operational and payment miscalculation. For instance, they might incorporate payments non-covered services, duplicate payments, eligibility, and receipt of a Medicare instalment when another payer had the principal obligation to make the payment.

Understanding Overpayments

Distinguishing excessive charges is the basic segment to the 60-day refund rule. There has been a lot of doubt among providers with respect to when an overpayment has been, actually, identified and when the 60-day “clock” starts ticking.

As indicated by the proposed rule, an overpayment is viewed as identified when a person has real information of the overpayment or acts in “reckless disregard or deliberate ignorance” of the presence of the overpayment. To encourage provider self-compliance, CMS has incorporated the “reckless disregard or deliberate ignorance’’ norms of the False Claims Act in spite of the fact that the statute doesn’t order this interpretation.

Steps for Reporting Overpayments

Ordinary overpayments can be reported by utilizing the overpayment method as defined by your carrier. For people who require a self-disclosure per OIG guidance, the reporting is done through the self-disclosure online submission process or perhaps through some other methods. This system gives you the opportunity to avoid the expenses and disturbances associated with a formal audit or review.

For doctor self-referral (Stark law) issues, CMS additionally recommended that a self-report of an overpayment together with a different CMS Self-Referral Disclosure Protocol must be submitted. The data CMS proposed to be submitted incorporates:

  • How the error was found
  • Scope of the issue
  • Cause of the error prompting excessive overpayment
  • Comprehensive strategy for corrective action, including systemic arrangements

For more on Medicare Overpayments, join expert speaker Wayne J. Miller, Esq., in this pre-recorded audio session “Medicare Overpayments: What Do You Do And When?”. This training session answers all your ‘what’ and ‘when’ questions on Medicare Overpayments. During this session, Wayne will specify best practices while responding to a discovered overpayment, as well as formal appeal procedures that are available to providers.

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