This rule provides needed clarity and consistency in the reporting and returning of self-identified overpayments. Since we are establishing a 6-year lookback period, we believe hospitals will have little, if any, additional record retention burden as the result of this rule. 1102, 1871, and 1874(e) of the Social Security Act (, Secs. Since the FCA is a fraud enforcement statute, commenters stated that it was not appropriate to apply this time period to all overpayments, which could also be caused by errors or mistakes that did not rise to the level of fraud. As a result, Congress addressed the significant differences between how all of these persons receive federal health care program dollars in the overpayment definition by including the term applicable reconciliation. Medicare Part A and B claims are submitted by providers and suppliers to contractors and those claims are expected to be correct when filed. Specifically, commenters stated that section 1128J(d) of the Act recognizes the deadline for submission of the initial cost report as tolling the 60-day time period and thus applicable reconciliation should mean a process that occurs subsequent to the submission of the initial cost report. What is Medicaid estate recovery? According to the comments, if the amount of the overpayment falls below this threshold, providers are permitted to return the overpayment through existing claims adjustment processes. Commenters requested that the final rule indicate that the duty to make a reasonable inquiry is only triggered by a notice of a contractor or government audit specific to a provider. Hi William! If the provider's or supplier's inquiry verifies the audit results, then it has identified an overpayment and, assuming there is no applicable cost report, has 60 days to report and return the overpayment. The OFR/GPO partnership is committed to presenting accurate and reliable Its essential to compare Medicare Advantage and Medigap plans before enrolling in either option. Comment: Several commenters noted that section 1128J(d) of the Act has two separate provisions addressing overpayments and questioned whether the proposed rule conflated those provisions. 5 the fol-lowing statements are submitted re-garding (1) the specific powers granted to Congress in the Constitution to enact the accompanying bill or joint resolution and (2) the single subject of the bill or joint resolution. In the event that a SDP settlement is not reached, the provider or supplier has the balance of the 60-day time period remaining from identification to the suspension of that 60-day period when OIG acknowledged receiving the SDP submission to report and return any overpayment to the contractor. Your email address will not be published. Find other ways to pay premiums. We believe that the concept of reasonableness is fact-dependent. Response: An adjustment to any individual paid claim constitutes a revised initial determination for purposes of the reopening rules. Can they really put money back into your social security check? Suggested minimum monetary thresholds ranged from $5 to $5,000. All ZIP Codes in the United States and its territories are eligible for the Give Back Benefit because they are all eligible for Medicare Advantage plans. (See the November 15, 2002 proposed rule (67 FR 69327).) An overpayment must be reported and returned regardless of the reason it happenedbe it a human or system error, fraudulent behavior, or otherwise. of this final rule regarding the claims adjustment processes as a way to report and return overpayments. You can also contact your licensed Medicare agent to receive assistance. Executive Order 13132 establishes certain requirements that an agency must meet when it announces a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on state and local governments, preempts state law, or otherwise has Federalism implications. Commenters suggested requiring contractors to return payments to providers and suppliers when the provider or supplier notifies the contractor that the funds were returned in error and requests a reversal. Commenters recommended we clarify that overpayments associated with cost reports be reported and returned through the existing cost reporting process. Commenters requested that CMS clarify that self-disclosure by providers and suppliers to other government entities, such as DOJ and MFCU, would similarly suspend the 60-day deadline. Similarly, commenters believed the following statement in our January 25, 2002 proposed rule (67 FR 3663) supports a more inclusive definition of applicable reconciliation: Submission of corrected bills in conformance with our policy, within 60 days, fulfills these requirements for providers, suppliers, and individuals.. In connection with this final rule, we are seeking authorization from OMB to collect financial information regarding overpayments using the 6-year lookback period. Accordingly, until notification of changes to the SRDP lookback period, providers and suppliers submitting to the SRDP may voluntarily provide financial information from the fifth and sixth years or report and return overpayments from the fifth and sixth years through other means. (ii) CMS acknowledges receipt of a submission to the CMS Voluntary Self-Referral Disclosure Protocol and will remain suspended until such time as a settlement agreement is entered, the person withdraws from the CMS Voluntary Self-Referral Disclosure Protocol, or the person is removed from the CMS Voluntary Self-Referral Disclosure Protocol. Additionally, providers and suppliers continue to be required to comply with our current procedures[1] The documents posted on this site are XML renditions of published Federal However, at this time, we are only authorized under the Paperwork Reduction Act to collect financial analysis of overpayments that occurred during a 4-year lookback period. Comment: Commenters stated that the 60-day time period should start to run on the day that an overpayment inquiry has concluded, confirmed that there has been an overpayment, and produced sufficient information to calculate the precise overpayment amount. Life Estates Response: We have revised the requirement to include the credit balance reporting process as a way to report and return overpayments under this final rule. Whether a hotline complaint qualifies as credible information is a factual determination. provide legal notice to the public or judicial notice to the courts. I replied. We may instruct the Medicaid State Agency to withhold the federal share of any Medicaid payments until the full amount owed to Medicare is recouped A provider may choose from these options when responding to an initial demand letter: Make an immediate payment Request immediate recoupment Submit a rebuttal This requirement exists even if the provider or supplier received the overpayment prior to March 23, 2010. Specifically, commenters requested clarity on how the provider or supplier could comply with the regulation by using a contractor form that did not contain all of the elements required by the regulation. Comment: Several commenters requested clarification about the level of resources a small provider or supplier is expected to devote to investigating potential overpayments in order to avoid being liable based on a theory of reckless disregard or deliberate ignorance. Some commenters expressed concern that resources might be diverted from patient care in order to ensure compliance with this rule. A person should have determined that the person received an overpayment if the person fails to exercise reasonable diligence and the person in fact received an overpayment. What is the Maryland Medicare Supplement (Medigap) Birthday Rule? Commenters stated that it is a common practice to include the probe sample in the expanded audit to extrapolate an error rate to the entire population. Commenters requested that CMS provide compliance guidance on how to develop compliance plans and conduct self-audits for small providers and suppliers and recommended that this guidance be coordinated with the rulemaking related to sections 6102 and 6401 of the Affordable Care Act. Comment: Some commenters objected to the example of an identified overpayment concerning a provider learning of services provided by an unlicensed or excluded individual. The $161.16 million estimate represents our primary, or mid-range, projection. Medicaid recipients over the age of 55 are expected to repay the government for many medical expensesand states will seize houses and other assets after those recipients die in order to satisfy. Again, 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. Response: We agree with the commenters to the extent that section 1128J(d) of the Act pertains only to overpayments. Opinions expressed by Forbes Contributors are their own. Any overpayment retained by a person after the deadline for reporting and returning the overpayment specified in paragraph (b) of this section is an obligation for purposes of 31 U.S.C. The burden associated with this requirement was the time and effort necessary to report and return the overpayment in the manner described at 401.305. Seniors have plenty of options regarding healthcare coverage, which is great because everyones needs are different. Section 1128J(d) of the Act provides that an overpayment must be reported and returned by the later of(i) the date which is 60 days after the date on which the overpayment was identified; or (ii) the date any corresponding cost report is due, if applicable. We understand that a common way to conduct an audit is to use a probe sample and then incorporate that probe sample into a larger full sample as the basis for determining an extrapolated overpayment amount. However, the commenter appears to believe that the physician only has an obligation to report and return the overpayment if the upcoding was done deliberately. Reasonable diligence includes both proactive compliance activities conducted in good faith by qualified individuals to monitor for the receipt of overpayments and investigations conducted in good faith and in a timely manner by qualified individuals in response to obtaining credible information of a potential overpayment. However, for claims, if the provider identifies an inaccurate outlier claim payment, the provider must follow the overpayment payment reporting process for claims, as noted in this final rule. We plan to announce the information collection request under the required 60-day and 30-day Federal Register notice and comment periods. For instance, if a supplier was paid $40 for a claim when it should have received $30, the commenters questioned whether the overpayment amount is $10 and not the entire $40 amount paid. These principles include randomly selecting claims from the population and extrapolating only within the time period covered by the population from which the sample was drawn. Response: The preamble to this final rule does not include the phrase all deliberate speed as the benchmark of compliance. 1302, 1395hh, and 1395w-5). Response: Yes, providers and suppliers may request a voluntary offset from the contractor. CMS incurs procurement costs because of opposition to its recovery. The authority citation for part 401 continues to read as follows: Authority: Enter your ZIP code to pull plan options available in your area. This rule clarifies requirements for the reporting and returning of self identified overpayments. Given the differences in cost report-related payments and the resources needed on both the provider and the contractor's part in the cost report process, we are considering establishing a minimum monetary threshold for cost report-related overpayments. Response: Medicare contractors have long been instructed to refer potential fraudulent conduct to law enforcement. In addition, commenters believed that the Secretary was not given retroactive rulemaking authority here. The change is reflected in 401.305(f) of this final rule. However, this revision to the reopening regulation does not extend the lookback period specified in 401.305(f). Therefore, commenters requested that CMS clarify that billing or other errors that would not impact the reimbursement amount that a provider receives would not constitute an overpayment for purposes of this final rule. These commenters noted that the preamble provides that providers and suppliers may receive information concerning a potential overpayment that creates a duty to conduct a reasonable inquiry to determine whether an overpayment exists. These commenters stated that 6 years is consistent with the more commonly applicable FCA statute of limitations as well as the statute of limitations for section 1128A of the Act, which contains a variety of civil monetary penalty (CMP) authorities applicable to Medicare and Medicaid, including the CMP applicable to section 1128J(d) of the Act. Can you really get a Medicare giveback from a Medicare Advantage plan? Other commenters pointed to the Federal Acquisitions Regulations (FAR) treatment of the time between first learning of an allegation and the requirement to disclose credible evidence of an overpayment. Revised initial determinations, which trigger appeal rights under the existing rules, are issued when specific claims are adjusted. We project an annual cost burden of between $120.87 million and $201.45 million. The final rule states that a person has identified an overpayment when the person has, or should have through the exercise of reasonable diligence, determined that the person has received an overpayment and quantified the amount of the overpayment. We interpret this language as showing the Congress intended to more clearly codify providers and suppliers' existing duty to return overpayments they have received, which would necessarily include taking appropriate actions to determine whether the provider or supplier has in fact received an overpayment. Comment: Some commenters questioned under what circumstances a provider would anticipate an outlier reconciliation will be performed at the time of cost report settlement and requested that CMS clarify that outlier payments may be returned via the overpayment reporting process for claims. Response: Hotline complaints received by a provider or supplier may qualify as credible information of a potential overpayment under this rule, which would require the provider or supplier to exercise reasonable diligence to determine if an overpayment has occurred. Response: As we stated in the preamble to the proposed rule, the examples were not intended to be an exhaustive list of overpayment situations. For purposes of 401.305 only, we estimated that approximately 125,000 providers and suppliers (or roughly 8.5 percent of the total number of Medicare providers and suppliers) would report and return overpayments in a typical year under our provisions. Response: We understand the commenters' concerns, but the 60-day deadline to report and return is contained in section 1128J(d) of the Act. For example, self-referral overpayments reported to us in accordance with the CMS Voluntary Self-Referral Disclosure Protocol (SRDP) prior to the effective date of this final rule will not be governed by the 6-year lookback specified in this final rule. Medicare contractors do not audit or reconcile every claim. Some may allow for funeral and burial expenses to be paid while others do not. To qualify for a premium reduction, you must: Thats a good question. To the extent that the return of any self-identified overpayment results in a revised initial determination of any specific claim or claims, a person would be afforded any appeal rights that currently exist, as some commenters stated. Therefore, the provider is not responsible to report and refund the overpayment until they have received the cap determination from their MAC. In 401.305(e)(1), we proposed to require the use of the existing voluntary refund process, which will be renamed the self-reported overpayment refund process, set forth by the applicable Medicare contractor to report and return overpayments except as provided in 401.305(e)(2). Finally, we proposed to define the term Person as a provider (as defined in 400.202) or a supplier (as defined in 400.202). While we understand the concern about receiving a timely acknowledgement response, we believe that this concern does not outweigh the benefit of using the government's acknowledgement to avoid any potential Start Printed Page 7679question as to whether the government actually received the submission. The term persons covered by section 1128J(d) of the Act is broadit covers not only providers and suppliers, but also Medicaid managed care organizations, MA organizations, and PDP sponsors. You must be enrolled in a plan that offers the give back benefit. Most hospitals and most other providers and suppliers are small entities, either by nonprofit status or by having revenues of less than $7.5 million to $38.5 million in any 1 year. Comment: Several commenters stated that they interpreted the preamble to the proposed rule as permitting providers and suppliers time to conduct a reasonable inquiry before the 60-day time period begins to run. Medicare Plan Finder makes it easy for anyone to find the best Medicare plans to fit their needs. Commenters offered a variety of alternative lookback periods: Response: We have carefully considered all of the comments on the lookback period and have concluded that 6-year time period is most appropriate for this rule. 353 of the Public Health Service Act (42 U.S.C. We also recognize that compliance programs are not uniform in size and scope and that compliance activities in a smaller setting, such as a solo practitioner's office, may look very different than those in larger setting, such as a multi-specialty group. Summary However, not all Advantage plans offer this benefit. Im receiving SS. Response: We understand the commenters concerns related to the definition of overpayment. Comment: Several commenters questioned how a hotline complaint could create a duty to conduct a reasonable inquiry. ++ Removed proposed paragraph (d), which specified 13 specific data elements that were to be included in the report that providers and suppliers use to report and return overpayments. As noted previously, the only burden associated with our proposed provisions involves the ICR aspects of reporting and returning overpayments. A few of these plans do not include prescription drug coverage. The proposed rule defined applicable reconciliation as occurring when a cost report is filed, except that any changes to the SSI ratio that affect the Medicare hospital disproportionate share payments and any reconciliation to outlier payments will not result in a refund obligation until such time as the final settlement of the hospital's cost report occurs. Youre probably skeptical about the idea of an insurance company wanting to give YOU money. Here, well share what goes into the pricing of a Medicare Supplement plan, how much an average top-rated plan will cost, and how you can determine the right Medicare Supplement plan for your budget. Our intention is to capture both of those activities in this final rule. By Mr. GALLAGHER: H.R. Medicaid Estate Recovery and Medicaid Payback Rules December 13th, 2012 Find out how to avoid Medicaid estate recovery. Find out if you qualify for SSDI benefits. Yes, Medicare Part B Premium Reduction is another term for the Medicare Give Back Benefit. There are no direct payments to beneficiaries. Response: These comments underscore our concern expressed in the proposed rule that some providers and suppliers might avoid performing activities to determine whether an overpayment exists. 29, January 2, 2004). ++ In paragraph (d)(2) (which was proposed paragraph (e)(2)), we added disclosure to the CMS Voluntary Self-Referral Disclosure Protocol (SRDP) as a method of satisfying the reporting obligations for self-identified overpayments. Any information we provide is limited to those plans we do offer in your area. Response: We agree with commenters. Response: We decline to adopt the commenter's suggestion. 3729(b)(1)). For the time period between March 23, 2010 and the effective date of this final rule, providers and suppliers may rely on their good-faith and reasonable interpretation of section 1128J(d) of the Act. Our proposed rule acknowledged that in some instances, we make interim payments to a provider through the cost year and that the provider reconciles these payments with covered and reimbursable costs at the time the cost report is due. Can Medicaid Take Your House? - Policygenius Currently, 48 states in the U.S. offer this benefit. Comment: A commenter requested confirmation that a provider or supplier may provide a single notification to the Department or its contractors to satisfy the report and return requirement and does not also need to use the SDP or SRDP. Key provisions of the 60Day Rule The 60day "clock" Credible information of an overpayment Duty to investigate and quantify Reasonable diligenceproactive and reactive The sixyear "lookback" period Reporting and refund process Impact of contractor audits Appeals Prepayment probe audits 3 7500 Security Boulevard, Baltimore, MD 21244, Medicare Reporting and Returning of Self-Identified Overpayments, Short-Term, Limited-Duration Insurance; Independent, Noncoordinated Excepted Benefits Coverage; Level-Funded Plan Arrangements; and Tax Treatment of Certain Accident and Health Insurance (CMS-9904-P), HHS Announces Actions to Protect Consumers and Lower Health Care Costs, South Dakota Expands Medicaid Bringing Health Coverage to More than 52,000 State Residents, Health and Human Services (HHS) Proposed Rule Clarifying Eligibility for a Qualified Health Plan through a Marketplace, Advance Payments of the Premium Tax Credit, Cost-sharing Reductions, a Basic Health Program, and Some Medicaid and Childrens Health In, HHS Releases Proposal to Expand Health Care for DACA Recipients. However, all providers and suppliers reporting and returning overpayments on or after the effective date of this final ruleeven overpayments received prior to the rule's effective datemust comply with the new regulatory requirements. Commenters also noted that this process is not the only way to make overpayment refunds and is usually only used when a refund is made by check and the overpayment was calculated using a sampling methodology. Any information we provide is limited to those plans we do offer in your area. Other commenters stated that the proposed rule inappropriately applies the FCA, specifically the reverse false claims cause of action, to honest mistakes or inadvertent overpayments. The accuracy of our estimate of the information collection burden. In proposed 401.301, we stated that subpart D sets forth the policies and procedures for reporting and returning overpayments to the Medicare program for providers and suppliers of services under Parts A and B of title XVIII. As you can see, plenty of options are available for your healthcare needs. 1395pp), in situations where the provider did not know and could not reasonably have been expected to know that the payment would not be made. We understand the commenters' concerns about the breadth of this definition and believe we have appropriately addressed them by expanding the ways in which overpayments may be reported and returned to include the claims adjustment or reversal and credit balance reporting process, as discussed in more detail in section II.C.4. The first step is to request a reconsideration of the Social Security Administration's initial determination (the amount being charged or deducted). Our primary, or mid-range, projection is an estimate of $161.16 million. Comment: Some commenters requested clarification that the fact that a contractor or the government determines that a claim constitutes an overpayment does not automatically mean that the provider or supplier should have reported and returned the overpayment at an earlier time. (2) A person satisfies the reporting obligations of this section by making a disclosure under the OIG's Self-Disclosure Protocol or the CMS Voluntary Self-Referral Disclosure Protocol resulting in a settlement agreement using the process described in the respective protocol. 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. Creating this standard for identification provides needed clarity and consistency for providers and suppliers on the actions they need to take to comply with requirements for reporting and returning of self-identified overpayments. However, the comments received indicated that this could cause needless additional burden. The quality, utility, and clarity of the information to be collected. Response: The cited language from the March 1998 proposed rule was addressing the Secretary's identification of overpayments, not overpayment identified by a provider or supplier, which is the subject of this rule. These commenters stated that the hardship standard was too difficult to meet. As is currently the case under the existing voluntary refund process, there are no appeal rights associated with the self-identified overpayments that do not involve identification of individual overpaid claims and individual claim adjustments. Commenters requested that CMS clarify that the rule does not apply in these situations. The product is the Medicare share of procurement costs. We do not believe that this burdenwhich, in any event, would only affect a small percentage of providers and supplierswould cause a particular provider or supplier to reduce the services it furnishes to beneficiaries. If Medicare Easy Pay doesn't start: Call us at 1-800-MEDICARE (1-800-633-4227). Limiting the standard for identification to actual knowledge would create that loophole and would conflict with the plain statutory mandate to report and return any overpayments the person has received. Comment: Other commenters requested clarification that a provider's obligation to inquire about potential overpayments extends only to the results of the contractor or government audit and not to other similar potential overpayments. Providers must maintain the appropriate documentation supporting the costs that are claimed on the cost report. The entries in Table 2 reflect the application of a 7 percent and 3 percent annualized rate to the high-end, primary, and low-end estimates referred to in section V. of this final rule. Live in a service area of a plan that has chosen to participate in this program.

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