Owe CMS a refund?
The likelihood of being overpaid at some point is inevitable. There are varying reasons for this. Regardless, CMS is proposing to change the game when it comes to starting the repayment process. In their proposed rule, CMS plans to change the existing language from “reasonable diligence” to verbiage that specifically aligns with their fraud and abuse language found in the (ACA). Verbiage such as “know”, “knowingly”, “reckless disregard”, and “deliberate ignorance”.
CMS is taking comments in regards to amending the standard for an identified overpayment. The deadline for submitting comments on file code CMS-4201-P, is by 5pm on February 13, 2023.
An overpayment can be self-identified by a provider, or identified by CMS or their MAC. Once self-identified, a provider must report and return the overpayment to their Medicare Administrative Contractor (MAC) within 60 days of identifying the overpayment. Or, 6 years from getting an overpayment, generally known as the “lookback period” or a corresponding cost report due date, if applicable.
When identified by CMS (or their MAC), either may initiate a refund recovery of any identified overpayment of more than $25, via demand letter.
There is an opportunity for the provider to submit a rebuttal or appeal. However, a rebuttal does not stop the recoupment activities. Coincidently, there are (5) levels available for a Part A or B provider appeal:
- Redetermination
- Reconsideration
- Hearing
- Review
- Judicial Review
For a deeper dive into the CMS Overpayment Requirements, please see the CMS MLN Matters 006379 fact sheet, released, July 2022. In addition to defining many of these processes, they also provides the timelines for recoupment activities.
Stay tuned for the final ruling on this one.