CMS publishes final rule on overpayments for Medicare Parts A and B

CMS has published a final rule that requires healthcare providers and suppliers receiving funds from Medicare Part A and Part B to report and return overpayments within 60 days of first identifying them.

“Our general aim of this final rule is to strengthen program integrity and to ensure that the Medicare Trust Funds are protected and made whole and that taxpayer dollars are not wasted,” the final rule stated. “An overpayment must be reported and returned regardless of the reason it happened—be it a human or system error, fraudulent behavior, or otherwise.”

Providers are liable for returning Medicare overpayments dated as far back as six years after the payment was originally received. This is a change from when the rule was first proposed back in 2012; the timeframe then was ten years, not six.

This change, CMS said, came after numerous comments claiming ten years was too long of a lookback period.

“After review of all the issues identified by the commenters, we conclude that a 6-year lookback period would appropriately address many of the concerns about burden and cost outlined previously,” the final rule stated. “Specifically, we note that, according to commenters, many providers and suppliers retain records and claims data for between 6 and 7 years based on various existing federal and state requirements. Thus, we believe our final rule does not create additional burden or cost on providers and suppliers in this regard.”

The rule also addressed the topic of “over-coding,” or “upcoding.” According to CMS, some commenters were unsure if “unintentional” upcoding would be in violation of the rules.

“To clarify, providers and suppliers must report and return overpayments identified as a result of upcoding, whether the inappropriate coding was intentional or unintentional,” the final rule stated.

Other commenters suggested to CMS that the lookback period for overpayments should be the same for underpayments. CMS made it clear that this final rule addresses overpayments, not underpayments, and underpayments have been touched on by previous policies.

A final rule from 2014 addressed the returning of overpayments for Medicare Part C and Part D. That rule can be read, in full, on the U.S. Government Publishing Office website.