Medicare Reporting & The 60 Day Rule

health law complianceBy: Karina Gonzalez

Earlier this year, CMS (Centers for Medicare and Medicaid   Services) released its  final rule related to  reporting  and returning  identified  Medicare and Medicaid overpayments for Medicare Part A and B. The rule is referred to as the “60-day rule” and it governs when an “identified” overpayment must be repaid to the government before it will be subject to liability under the federal False Claims Act (FCA), Civil Monetary Penalties Law and exclusion from the federal health care programs.

The Final Rule went into effect on March 14, 2016

An overpayment is “identified” for the purposes of reporting and overpayment under the 60-day rule when a provider or supplier “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.”

The 60 day clock starts ticking when a provider has “credible information” of a potential overpayment.  If the provider decides there is credible information, the next step is to exercise reasonable diligence in investigating the information to determine whether the provider has received and overpayment and if so, the overpayment must be quantified.    It is at the end of this process that the 60-day clock starts running.  Essentially the provider has all of the information necessary to now report the overpayment and make arrangements to return the overpayment.

Overpayment must be reported and returned only if the provider identifies the overpayment within 6 years of the date the overpayment was received.  So the 60-day rule has a lookback period of 6 years.

To return the self-identified overpayment the provider must use an applicable claims adjustment, credit balance or self-reported refund or another process to satisfy the obligation.

Providers and Suppliers should have an internal self-review process to diligently investigate and identify overpayments. They need to make sure that any discovered overpayments are acted on promptly in compliance with the 60-day rule.  They should also have a process in place to   review and investigate information from sources outside the organization that report billing, coding, reimbursement and other errors which may result in overpayments.


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