• ONUS on Health Care Providers to Repay Overpayments
  • April 25, 2011
  • Law Firm: Wilson Elser Moskowitz Edelman Dicker LLP - New York Office
  • Under the 2009 Fraud Enforcement and Recovery Act (FERA) and the 2010 Patient Protection and Affordable Care Act (PPACA), health care providers are obliged to report and repay identified overpayments received from government payment programs. The FERA and PPACA require that these overpayments must be reported and repaid within 60 days of their identification by a provider. As of this writing, no interpretive guidance has been issued by federal agencies such as the U.S. Department of Health & Human Services; U.S. Department of Justice, Office of the Inspector General (OIG) and the Centers for Medicare & Medicaid Services (CMS).

    Medicaid payments are covered by the FERA and PPACA amendments. The Office of the Medicaid Inspector General (OMIG) is developing a compliance roadmap, although it has not published interpretive guidance.

    We understand that OMIG is looking to its self-disclosure process as a template for making FERA/PPACA disclosures and payments. Pending guidance from federal agencies, OMIG is expected to interpret the FERA and PPACA amendments regarding Medicaid overpayments as follows:

    • Repayment is required for overpayments that are actually identified; overpayments that
       might have been identified are not covered at this time.
    • At a minimum, within 60 days, a provider should inform OMIG that it has identified an
       overpayment and provide a status report on its investigation and its expected completion date.
    • Payment within 60 days is expected only if the investigation and repayment calculations
       have been completed by the provider and verified by OMIG.
    • For claims under $5,000, a provider may use voids if the claims are eligible for voiding
       according to the Medicaid Provider Manual.
    • If claims under $5,000 are not eligible for voiding, then the provider must send a cover letter
       and a check to Computer Sciences Corp. (CSC).
    • For claims over $5,000, repayment is made to OMIG, as is currently the case with the
       self-disclosure program.
    • The process for informing OMIG and arriving at an agreed-upon repayment is the same
       regardless of whether the amount in question is under or over $5,000.

    OMIG is currently looking into issues for which an established reconciliation process exists, such as the treatment of amounts reserved in anticipation of rate changes and rate appeals.