CMS publishes final rule on Medicare overpayments

February 18, 2016
Area(s) of Interest: Payor Issues and Reimbursement Public Payors 

On February 8, the Centers for Medicare and Medicaid Services (CMS) published new rules on how physicians must handle overpayments from Medicare. According to the final rule, physicians must not only return Medicare overpayments within 60 days of identifying them, but they must also actively look for overpayment through self-audits and other forms of research.

While CMS does not think that the requirement is burdensome for physicians, in 2012 the American Medical Association and the California Medical Association asked CMS to clarify the look back duties for Medicare overpayment. In announcing the new rule the agency said self-audits, compliance checks and other types of research did not represent a new government mandate.

"Providers and suppliers have a clear duty to undertake proactive activities to determine if they have received an overpayment or risk potential liability for retaining such overpayment," the agency stated.

The new regulations come under a section of the Affordable Care Act that requires physicians, hospitals and other providers to return overpayments that they identify on their own. One draft of the overpayments rule required physicians to look back through 10 years of claims to make sure Medicare had not overpaid them, but the final rule requires only a six-year look back.

“Specifying the length and other parameters of the look back period provides additional clarity for providers and suppliers who have identified an overpayment," the agency noted in a fact sheet about the rule.

Even without the new regulations, CMS said, physicians are obliged under existing law to return Medicare overpayments, and if they do not do so, they can be held liable under federal law and face exclusion from government health care programs.

Click here to read the overpayment regulation on the CMS website.

Contact: Cheryl Bradley, (213) 226-0338 or cbradley@cmadocs.org.


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