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Understanding the New CMS Overpayment Rule

Written by Tammie Lunceford on April 27, 2016

Written by: Tammie Lunceford

On February 11, 2016, the Centers for Medicare and Medicaid Services (CMS) released the final rule for overpayments.  Overpayments have been discussed over the last two years, but the guidelines were vague and interpretation was difficult.  The new final rule is clear as a bell, including clarity on the 60 day reporting period.

Our healthcare team has discussed the impact of overpayments during year-end meetings with our clients, but it is evident most practices do not have a process to identify overpayments in their revenue cycle process. Many administrators have reported difficulty in discussing overpayments with physicians, once the money is received the physicians are reluctant to return the payment.

Part B News reports clarification on the 60 day clock stating the 60 days begins after a period of inquiry to identify and qualify the overpayment. The final rule does not include a time limit for the provider’s investigation, but CMS stated no more than six months would be reasonable.

The most important aspect of the overpayment rule is the fact that over-coding counts! If the electronic medical record template is increasing the level of provider’s coding relative to the supporting documentation including the diagnosis code, you could have reason for concern. Many providers do not understand how to analyze the elements in an evaluation and management visit, nor are they instructed on coding during their clinical training. It is important to know how your provider’s coding compares to utilization patterns of other physicians in the same specialty.

What else constitutes an overpayment?

  • Medicare payments for non-covered services
  • Medicare payments in excess of the allowable amount for an identified covered service
  • Errors and non-reimbursable expenditures in cost reports
  • Duplicate payments; and
  • Receipt of a Medicare payment when another payer had primary responsibility for payment.

Providers should expect increased enforcement now that the final rule has been released.  Administrators should compare each providers coding patterns to the utilization patterns of other providers in the same specialty.  A certified coder should be able to access the utilization patterns for comparison.  Practices should prepare a process for internal audits to identify problems and provide an opportunity for additional education.  If your practice has a compliance plan, you are more than likely already performing internal audits.  Be sure you are following your compliance plan if you have prepared one, the worst thing you can do is to have a policy that you do not follow.

Follow these tips to identify overpayments:

  • Prepare a report that identifies credit balances or overpayments each time you report month end revenue.
  • Prepare a process to work each credit and identify true overpayments.
  • Treat overpayments seriously! Pay Medicare and Medicaid overpayments timely.
  • Prepare policies and procedures to assure an overpayment process is included in the revenue cycle.

A robust compliance plan includes a process for employees to anonymously report fraudulent activity or concerns of misconduct. If a practice receives a complaint from a caller, patient or employee, it should be investigated if sufficient details are given to substantiate the claim.  Be ready to defend your actions.  Contact a Warren Averett healthcare team member for assistance in preparing policies and procedures for overpayments.


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