Posts Tagged ‘overpayment’

CMS Will Deny Enrollment Applications When Outstanding Overpayment Exists

In Uncategorized on August 23, 2013 at 7:16 pm

Effective October 1, 2013, any providers or owners of provider-entities having an existing or delinquent overpayment that has not been repaid in full at the time of the enrollment application or change of ownership filing may be denied that new enrollment or change of ownership until that overpayment has been addressed. 

Upon receipt of the CMS enrollment forms (855A, 855B or 855S application), the Medicare Contractor will determine – whether any of the owners listed in Section 5 or 6 of the application has an existing or delinquent Medicare overpayment.  Upon receipt of a CMS-855I application, the Medicare Contractor will determine whether the physician or non-physician practitioner has an existing or delinquent Medicare overpayment.

If an owner, physician, or non-physician practitioner has such an overpayment, the contractor shall deny the application, using 42 CFR 424.530(a)(6) as the basis. The denial shall be issued regardless of:

  • Whether the person or entity is on a Medicare-approved plan of repayment or payments are currently being offset:
    • Whether the overpayment is currently being appealed
    • The reason for the overpayment

For now this rule applies only to initial enrollments and new owners in a CHOW, not revalidations or updates to current enrollments.  Note also that if the Medicare Contractor determines that the overpayment existed at the time the application was filed, but the debt was paid in full by the time the contractor performed its review, the contractor will not deny the application because of that overpayment.


CMS Published Proposed Rules on Reporting of Overpayments

In Uncategorized on August 22, 2013 at 6:05 pm

Reminder to be mindful of proper management of overpayments!

In spring 2012, CMS released a Notice of Proposed Rulemaking (NPRM) that would, if finalized, require providers and suppliers to report and return self-identified overpayments either within 60 days of the incorrect payment being identified or on the date when a corresponding cost report is due, whichever is later.

In addition to the 60-day reporting requirement, CMS is also proposing that providers retain medical records for at least 10 years in order to allow for a look-back for the identification of billing errors that may have occurred in previous years. 

The announcement is one part in a series of steps Medicare is taking to “protect taxpayer dollars.” In addition to the overpayment reporting requirements, CMS is: using private auditors to identify so-called wasteful spending before it happens; expanding the use of Recovery Audit Contractors to the Medicaid program; testing changes to hospital billing systems to help prevent over-billing; and, changing the process for approving payments for durable medical equipment with historically high payment error rates.

The Proposed Rule identifies a Medicare overpayment as “funds that a person receives or retains under Medicare to which the person is not entitled.”  The NPRM provides examples of overpayments in Medicare to include:

  • Duplicate submission of the same service or claim
  • Payment to the incorrect payee
  • Payment for excluded or medically-unnecessary services
  • Payment for non-covered services

Any failure to report and return the overpayment within the applicable time frame could be a violation of the False Claims Act.  Providers also could be subject to civil monetary penalties or excluded from participating in federal healthcare programs for failure to report and return an overpayment.

The Medicare Over Payment Proposed Rule ( is available for public inspection.  The link also provides instructions for how to submit comments.