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Medicare and Medicaid Overpayments: Meeting the Refund and Reporting Obligations and Avoiding Program Exclusions and False Claims Act Liability

(870 reviews)

Produced on June 17, 2015

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Course Information

Time 91 minutes
Difficulty Advanced
Categories Health Care

Course Description

Health care providers are required by law to report and return overpayments to Medicare and Medicaid. It does not matter whether the overpayment was caused by Medicare contractor error or a mistake by the provider.  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, etc.


The law requires Medicare and Medicaid overpayments within certain time parameters. Providers that do not properly report and refund overpayments risk violating the False Claims Act, civil monetary penalties, and/or program exclusion.  There are special rules that apply when the patient is in a Medicare or Medicaid managed care plan, or a Medicare Part D plan.


In this presentation, Robert Roth of Hooper, Lundy, & Bookman discusses how providers must determine the amount of overpayment, the reporting and refund obligations, as well as the government's recovery rights when considering whether, when, and to whom to make repayments to Medicare and Medicaid.


Learning Objectives:

I.      Identify when repayment/disclosure is not voluntary – the origins and scope of the 60-day report and repayment statute

II.     Analyze the Final Rule on implementation of 60-day statute for Medicare Parts C and D

III.    Summarize the updates on Proposed Rule for Medicare Parts A and B

IV.    Describe the Proposed Rule for Medicaid Managed Care

V.     Discuss which agency an overpayment should be reported to

VI.    Discover practical considerations when investigating overpayments and preparing disclosures

VII.   Describe the updates on pending 60-day statute litigation


Credit Information

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Robert L. Roth

Hooper, Lundy & Bookman, P.C.

Robert L. Roth, a Managing Partner at Hooper, Lundy & Bookman, P.C.'s Washington, D.C. office, advises clients on matters arising under Medicare and Medicaid, focusing on payment, compliance, and licensing issues. A former senior attorney for the Centers for Medicare & Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS), and a former Assistant Attorney General for the State of Maryland, Mr. Roth represents a wide range of clients on federal and state regulatory and business matters. He also represents clients in litigation at the state and federal trial and appellate court levels, as well as before state and federal administrative tribunals, including the Provider Reimbursement Review Board. Mr. Roth is one of the select few health lawyers to have argued before the United States Supreme Court, which he did in Sebelius v. Auburn Regional Medical Center, 133 S.Ct. 817 (2013).


Mr. Roth represents providers and other clients throughout the country on matters such as reimbursement, overpayment refunds/disclosure, and coordination of benefits. He also actively counsels clients on complying with the issues surrounding all aspects of the Medicare/Medicaid programs, including the Medicare Secondary Payer (MSP) statute. Ranked by clients and peers as one of the leading health care attorneys in Washington, D.C. by Chambers USA, Bob was described as “zealous and committed” and as “stand[ing] out as having second-to-none knowledge of Medicare Secondary Payer issues.”


Mr. Roth began practicing privately in 1993 following an 11-year career in government, during which he served at both the state and federal levels. At the federal level, he represented the Health Care Financing Administration (subsequently renamed CMS) as part of the HHS Office of the General Counsel. While in that position, Mr. Roth was awarded the General Counsel’s Excellence in Legal Services Award for Outstanding Conduct in Counseling and Representing the Health Care Financing Administration in Medicare Litigation and the HHS Inspector General’s Integrity Award. Earlier, at the state level, Mr. Roth served as an Assistant Attorney General, representing Maryland’s Department of Health and Mental Hygiene on state regulatory issues, after serving the Maryland General Assembly as Counsel to the Constitutional and Administrative Law Committee of the Maryland House of Delegates and the Commission to Revise the Annotated Code of Maryland.

Mr. Roth received his undergraduate degree from Lehigh University in history and Latin and his juris doctorate from Syracuse University College of Law.


Representative Matters

  • Mr. Roth’s significant litigation experience includes advising clients through the largest court settlement ever in a Medicare reimbursement case. He successfully argued in Monmouth Medical Center/Staten Island University Hospital v. Thompson, 257 F.3d 807 (D.C. Cir. 2001), that the reopening prohibition in HCFA Ruling 97-2, which prevented the plaintiff hospitals from having their disproportionate share hospital (DSH) payment recalculated, was unlawful and that the court had mandamus jurisdiction to hear the hospitals’ challenge. As a result of this decision, 253 lawsuits involving more than 600 hospitals were brought in the United States District Court for the District of Columbia and consolidated under the umbrella case name In Re: Medicare Reimbursement Litigation. Mr. Roth was named one of four members of the Plaintiffs’ Coordinating Counsel, which negotiated a settlement of more than $665 million to resolve the pending lawsuits.
  • Mr. Roth’s client work also includes the successful resolution of OSF Healthcare System, Inc., d/b/a Saint Francis Medical Center v. Thompson (D.D.C.), where the client was seeking an order requiring the Secretary of HHS to delete certain MSP regulations from the Code of Federal Regulations.



Robert E.

Outstanding historical, political, and philosophical overview and approach to presentation gave a real understanding of athe complex issues involved.

Joseph C.

Excellent instructor

Stacey W.

excellent presentation.

Laura S.

very knowledgeable speaker. very good presentation

Andrietta W.

Presenter was very knowledgeable and informative.

Andrew D.

Good program

Julie A. B.


Ellen C.

Very informative

James H.

very very detailed statutory and regulatory analysis

Joel E.


Gary D.

Very informative presentation encompassing a range of very complicated issues.

Rebecca J.

Excellent presentation about an evolving area of the law.

Stuart G.

Pretty dense, but useful

Melody H.

very informative and a great speaker

Alexandra S.

Hypotheticals were useful

Richard L.

Instructor had first-hand knowledge of material and effectively conveyed it

Alan H.

clear and comprehensive.

Caroline P.

This is a very complicated topic esp. if you don't do this everyday. This presentation was very help and I will use a lot of the information received today to benefit my employers.

Brent W.

Good speaker.

Richard E. K.


Gurudev A.

Very informative presentation. I would love to see some more CLE presentations from Mr. Roth as this is a complex and fast evolving area of practice that I have had some significant involvement with. The well is very deep and presentations like this are

Carolina S.

great - very clear and useful

Renee P.

Mr. Roth clearly had experience and knowledge about this very complex topic.

Michael T T.

Excellent presenter.

Joung Ho K.

Speaker explained the 60 day rule for payment after identification quite well.

Holly T.

Nice slides and awesome to have the citations on them for future reference or use.

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