How to address Medicare overpayment claims

Doctors are extremely busy. In addition to caring for their patients, regulations force healthcare providers to fill out seemingly endless paperwork. Medicare Parts A and B healthcare providers face the additional burden of ensuring, at risk of punishment, that all of their received Medicare payments are correct.

In some cases, healthcare providers receive more money from Medicare than they are legally entitled to, known as an overpayment. The overpayment may be the fault of the provider due to a number of factors including: over-billing services, duplicating Medicare submissions or writing down incorrect codes. In other cases, Medicare is responsible for accidentally overpaying a healthcare facility. What should the healthcare facility do if it receives an overpayment?

Healthcare provider’s response to an overpayment

Regardless of the cause for overpayment, the provider is responsible for notifying Medicare of the overpayment and returning funds.

The healthcare provider has 60 days after recognizing an overpayment to return the overpayment amount. It is the healthcare provider’s responsibility to proactively look for Medicare’s re-imbursement mistakes and to rectify any issues. Additionally, providers must explain the reason for the overpayment to Medicare.

Doctors may think that they are in the clear if they do not find any overpayment mistakes. However, they are legally responsible for any overpayments that Medicare thinks that they should have been able to identify through “reasonable diligence.” Therefore, an honest oversight could get a healthcare provider into serious trouble.

Penalties for failing to address overpayment

Unfortunately, it may be easy for a healthcare facility to miss an overpayment, but the consequences can be severe.

Physicians may face heavy fines ranging between $5,500 to $11,000 for each incorrect claim, and fees totaling up to three times the government’s sustained damages. Additionally, doctors may lose their ability to participate in Medicare, and their professional reputation is at risk.

The Texas Health and Human Services Commission invests substantial resources seeking out overpayment claims. If you are struggling to deal with the government over an overpayment claim, contact an attorney who can help you navigate Medicare’s regulations and determine the best course of action to take.

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