Medicare / Medicaid Overpayments

If you have received an overpayment notice from Medicare or Medicaid, immediate action is required. While you may not have done anything wrong, and therefore think you can ignore it, that notice could lead to civil, criminal and administrative enforcement actions against you and your company.

Many clients believe they can handle the inquiry themselves, but doing so generally leads to even more problems. That is why it is essential that you contact legal counsel immediately. The mishandling of overpayments can trigger a criminal fraud investigation or a civil action under the federal or state False Claims Act.

The Health Law Offices of Anthony C. Vitale has extensive experience representing clients in audits and overpayments and we can represent your interests through all of the stages of the overpayment appeals process in an effort to achieve the most successful results.

An overpayment notice is generated by an audit conducted by a Recovery Audit Contractor (RAC) a Medicare Administrative Contractor (MAC), a Zone Program Integrity Contractor (ZPIC) or a Medicaid Integrity Contractor (MIC).

Examples of overpayments include:

  • Deductible or co-insurance was applied incorrectly
  • Payment exceeded reasonable charge
  • Duplication of charges or claims
  • Payment for which the individual was not entitled to benefits under Medicare/Medicaid
  • Payment for non-covered or medically unnecessary items or services
  • Services incorrectly coded
  • Services not rendered
  • Services rendered by an unlicensed or excluded provider

Under the Affordable Care Act’s (ACA) overpayment provision and rules promulgated by the Centers for Medicare & Medicaid (CMS), a provider who has received an overpayment must report and return it. The deadline is the later of the date that is 60 days after the overpayment’s identification or the due date of any applicable corresponding cost report. Failure to report and return the overpayment can result in False Claims Act and Civil Monetary Penalties Law liability, as well as exclusion from federal healthcare programs.

Once an overpayment is identified, there are strict guidelines that must be adhered to when it comes to the appeals and recoupment process.

Providers would be well advised to schedule regular reviews of their compliance program documents and standards. In addition to assisting you once you become the target of an overpayment notification, the Health Law Offices of Anthony C. Vitale can help you to create a program designed to keep you in compliance with existing laws.