A Review of the Final Rule Implementing the Medicare Overpayment Mandatory 60-Day Refund Statute

Health care providers are required by statute to report and return overpayments to Medicare and Medicaid. It does not matter whether the overpayment was caused by Medicare contractor error, a mistake by the provider, or action by a third party. Overpayments arise in a variety of circumstances - the claim was for services not covered, the services were not medically necessary, the payment was for a higher level of services than performed, the payment was for a Stark law prohibited violation, Medicare paid primary when another payer was properly primary, etc.  

The law requires providers to report and refund Medicare and Medicaid overpayments within 60 days after the overpayment is identified. Providers that do not properly report and refund overpayments risk False Claims Act liability, civil monetary penalties, and/or program exclusion.  

On February 12, 2016, CMS published the final rule implementing the 60-Day mandatory refund statute for purposes of Medicare Parts A and B. This final rule, which affects virtually every Medicare provider, is a mixed bag – somewhat helpful but potentially costly to providers. Moreover, although ostensibly about overpayments, this final rule is vast, also touching on compliance plans, Stark, kickbacks, appeals, reopening, limitation on liability, use of sampling, Medicare secondary payer, and more.

In this presentation, Robert Roth of Hooper, Lundy, & Bookman, a leading authority on Medicare overpayments, discusses the good, the bad, and the ugly in this final rule, including the time in which providers must complete their investigations and make refunds to Medicare. In-depth understanding of this final rule is essential for all providers. 

Learning Objectives:

I.     Review of the 60-day mandatory refund statute

II.    Analyze the February 12, 2016 final rule implementing the 60-day statute for purposes of Medicare Parts A and B

III.   Discuss the effect of the final rule on provider operations in-depth

IV.   Identify practical considerations when investigating overpayments and preparing disclosures

V.    Understand any updates on pending 60-day statute litigation