Medical Billing and Coding Healthcare Blog

The Centers for Medicare & Medicaid Services (CMS) has published a final rule on reporting and returning self-identified Medicare overpayments.

The rule is specifically for Medicare parts A and B healthcare providers and suppliers. A separate final rule was published in May 2014 that addressed Medicare Parts C and D overpayments.

The major provisions for providers in the new rule are as follows:

  • An overpayment must be reported and returned by the later of the date which is 60 days after the date on which the overpayment was identified or the date any corresponding cost report is due (if applicable).  
  • An overpayment is "identified" if the person has actual knowledge of the existence of the overpayment or acts in reckless disregard or deliberate ignorance of the overpayment.
  • Overpayments must be reported and returned only if a person identifies the overpayment within six years of the date the overpayment was received. Note: The original overpayments rule required physicians to look back through 10 years of claims to make sure Medicare had not overpaid them
  • Providers must use an applicable claims adjustment, credit balance, self- reported refund or another appropriate process to satisfy the obligation to report and return overpayments.
  • If a provider has reported a self-identified overpayment to either the self-referral disclosure protocol managed by CMS or the self-disclosure protocol managed by the Office of the Inspector General, the provider or supplier is considered to be in compliance with the provisions of this rule as long as they are actively engaged in the respective protocol.

Access the final rule here.

Providers that fail to report and return an overpayment could face potential False Claims Act liability, Civil Monetary Penalties Law liability and exclusion from federal healthcare programs. Reduce your practice's risk of getting sued by the government due to missed overpayments by outsourcing your billing to Physicians Group Management (PGM), a leading medical practice management company. For 35 years, PGM has provided physicians with a wide range of innovative solutions that help practices run more efficiently, including a robust medical billing service backed by a team of experienced, certified coders and billers.      

PGM Billing, one of the nation's leading medical billing companies, is profiled in a recent report by Becker's Hospital Review.

The report identifies companies that provide revenue cycle management solutions specific to the healthcare industry.

PGM's profile reads as follows:

"Physicians Group Management (Lyndhurst, N.J.). PGM, founded in 1981, offers physician billing services, facility billing services and EMR solutions. The company offers billing solutions specifically tailored to a number of different specialties including allergy and immunology, anesthesiology, cardiology, chiropractic, dermatology, emergency medicine, gastroenterology, mental health, nephrology, oncology, orthopedics, pain management, primary care and urology."

As the report notes, "Revenue cycle management is essential to any business's strategy. These processes are only growing in importance in healthcare as every dollar is expected to stretch further than before."

According to the Healthcare Billing & Management Association, "Revenue cycle management (RCM) is the process that manages claims processing, payment and revenue generation. It entails using technology to keep track of the claims process at every point of its life, so the healthcare provider or medical billing company doing the medical billing can follow the process and address any issues, allowing for a steady stream of revenue. The process includes keeping track of claims in the system, making sure payments are collected and addressing denied claims. RCM encompasses everything from determining patient insurance eligibility and collecting co-pays to properly coding claims using CPT and ICD-9 codes."

Of RCM, MedPageToday writes: "RCM is the lifeblood of every practice. Effective patient registration, insurance and benefit verification, charge capture, and claims processing are essential to maintaining viability."

Becker's Hospital Review features up-to-date business and legal news and analysis relating to hospitals and health systems. Content is geared toward high-level hospital leaders (CEOs, CFOs, COOs, CMOs, CIOs, etc.), including hospital and health system news, best practices and legal guidance specifically for these decision-makers.

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