Medicare Overpayments and Defalcation Reversal: A Resource for Providers
Seniors and those with certain impairments in the United States are covered by Medicare, a vital health insurance program. The federal government provides both the funding and the administrative oversight for the program, which is run by the Centers for Medicare & Medicaid Services (CMS). One of the laws and regulations that Medicare providers must follow is the handling of overpayments.
The uncommon issue of Medicare overpayments was recently brought up by Doctor Ronald Hirsch. In this case, the practitioner gets an ABN from the patient in advance of the elective surgery. The ABN alerts the patient to the possibility that the operation may not be covered by Medicare and that the patient may be liable for paying the cost. If the patient gives their consent, the practitioner may charge Medicare for the treatment, but they must include a G-code to let the MAC know that they have received an ABN and are not expecting payment
However, there are situations in which the MAC pays the claim anyway, even when the provider has previously received a far larger payment from the patient at the time of treatment. The supplier is obligated to refund one of the payments in such a scenario. Which money should be refunded, and how can legality be ensured?
The FCA is implicated here because of the possibility of a reverse false claim. Overpayments made by the government are covered by the FCA’s “reverse” section, which was created for that purpose. There is no need to establish either the use or the materiality of a false record or statement; rather, it is sufficient to show that the defendant deliberately hid or illegally avoided or reduced a duty to pay the government.
To avoid running afoul of the FCA, providers need a solid revenue integrity mechanism in place to quickly identify duplicate payments and efficiently reconcile the underlying causes. Providers must also have a “front-end” process to reliably identify services for which CMS will not reimburse payors, as well as a patient-relations program to provide a thorough explanation to the patient regarding the ABN, the payment (if collected), and the subsequent refund.
Providers who are certain their services are not covered by Medicare must return any Medicare payments they have received along with an explanation using the MAC’s designated reporting and refunding form. If the provider is unsure whether or not the service is covered by Medicare, it may choose to keep the Medicare payment and refund the patient’s share. The CMS payment is still susceptible to scrutiny and refusal at a later time, and the provider is placing trust in the MAC’s discretion and interpretation of CMS payment regulations, which may or may not be correct.
To sum up, Medicare-approved providers must be watchful and aggressive in order to stay within the letter of the law and protect the Medicare system. Patients may be harmed if the kept money is audited and recouped at a later date. Because of this, it is crucial to have a solid revenue integrity system, a front-end mechanism to detect non-reimbursable treatments, and a patient-relations program to provide thorough explanations to patients concerning ABNs and overpayments. By taking these precautions, we can ensure that both patients and the government can continue to have faith in our healthcare system (fast and accurate credentialing).
