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Medicare & Medicaid Deadline For Overpayment Clarified

60 Days Medicaid and Medicare RuleFederal Court Finds Sixty Day Rule Deadline Begins to Run When Put on Notice of Potential Overpayments

When the Affordable Care Act (ACA) was passed, a new requirement for reporting overpayments was created. This new obligation, often referred to as the ‘Sixty Day Rule’ requires providers who receive an overpayment of Medicare or Medicaid funds to “report and return” the overpayment to the government.

According to the statute, an overpayment must be reported and returned within sixty days of the “date on which the overpayment was identified.” Failing to do so is a violation of the False Claims Act.

Although Centers for Medicare and Medicaid Services (CMS) has provided some guidance on when an overpayment is “identified” within the context of Medicare, now a New York Federal Court has weighed in on the meaning and application of the ACA sixty-day rule as it applies to Medicaid.

In a case before a New York Federal Court, the U.S. Department of Justice asserted that a hospital improperly billed Medicaid in 2009 and 2010 and violated the FCA by delaying the return of overpayments. Such overpayments were the result of a billing system software glitch. The case was brought with the assistance of a former employee who had investigated the issue. Such employee had provided to hospital administrators a list of around 900 claims that were likely affected by the glitch which was subsequently ignored by the hospital.

The Court had to decide how to define the key term in the statute – “identified.” In the case, the former employee had not conclusively proven the identity of any overpayments. As it turned out, hundreds of the claims he listed had not actually been overpaid. However, he did recognize nearly five hundred claims that did in fact turn out to be overpaid as worthy of attention.

After looking at the legislative history and purpose, the Court concluded that the 60-day clock begins ticking when a provider is put on notice of a potential overpayment, rather than when the overpayment is conclusively ascertained. This holding is in line with CMS’s patchwork of guidance for Medicare overpayments.

As a result, providers facing a potential overpayment must take action immediately to meet the 60 day deadline and avoid False Claims liability. Every health care practice should have a protocol in place to ensure that possible overpayments are investigated in a timely manner and such investigation is documented appropriately. Failure to report overpayments within that time frame could subject providers to huge penalties.  

If you have any questions about the 60-day rule or need assistance with investigating and reporting a potential overpayment contact Danielle Hildebrand at

Center for Medicaid & Medicare Services Shows Georgia Hospital Charges Vary

Center for Medicare & Medicaid ServicesA new study released by the Center for Medicaid and Medicare Services demonstrates that hospital charges for in-patient surgical and life threatening procedures vary greatly – including those in Georgia. The report looks at hospital-specific charges for the more than 3,000 U.S. hospitals that receive Medicare Inpatient Prospective Payment System (IPPS) payments for the top 100 most frequently billed discharges, paid under Medicare based on a rate per discharge using the Medicare Severity Diagnosis Related Group (MS-DRG) for Fiscal Year (FY) 2011. These DRGs represent almost 7 million discharges or 60 percent of total Medicare IPPS discharges.

Discrepancies for in-patient services in Georgia include:

Joint replacement or reattaching a limb:

  • Saint Josephs: up to $28,000
  • Northside: on average $62,000
  • Grady: up to $85,000

Treatment of pneumonia or pleurisy:

  • Grady: up to $19,000
  • Atlanta Medical Center: up to $41,000
  • North Fulton Regional in Roswell: up to $55,000

Admissions and treatment for life threatening conditions such as heart failure and stroke:

  • DeKalb Medical Center: up to $15,000
  • Atlanta Medical Center: up to $40,000
  • North Fulton: up to $58,000

The Center for Medicaid and Medicare Services issued the report in response to President Obama’s efforts to make the country’s health care system more affordable and accountable. To review the Center’s findings in Excel, click here. 



Georgia Medicaid Providers Can Now Access HP Online Portal

Georgia Health PortalAccording to a press release issued by the Georgia Chapter of the American Academy of Pediatrics, currently enrolled and future Georgia Medicaid providers can now access the HP online portal to submit their attestation to become eligible for the Affordable Care Act (ACA) Rate Increase. The initial enrollment period will last until July 31, 2013. When accessing the site, click on “Provider Information”, then select “Forms”, and then select the “Enrollment” link.

For more information, click here

Office of Inspector General’s 2013 Work Plan Increases Focus on Hospital Billing and the Affordable Care Act

Last month the Office of Inspector General (“OIG”) released its Work Plan for Fiscal Year 2013 (“FY 2013 Work Plan”).  The FY 2013 Work Plan focuses on many of the same areas as the prior year; however, there are two areas that received extra attention:  hospital billing and payment issues and implementation of the Affordable Care Act (“ACA”).

For Medicare purposes, the OIG has added new reviews including:

  • the efficiency of edits to identify hospital claims that were billed as discharges when they should have been billed as transfers
  • costs resulting from inpatient hospital claims for canceled surgical procedures
  • savings resulting from new payments for swing-bed services at critical access hospitals

One area of increasing focus in the Medicaid arena is prescription drugs.  In FY 2013, the OIG intends to explore alternative payment methods for home blood-glucose test strips.  The cost-saving means include rebates and competitive bidding, both of which have been successful at reducing net payment rates in some states.

Finally, the OIG will continue to monitor the ongoing implementation of the ACA.  Actions that the OIG intends to take in FY 2013 include the following:

  • reviewing compliance of home health agencies with the ACA requirement that physicians or other certain practitioners have face-to-face contact with beneficiaries
  • exploring cost savings associated with rental rather than purchase of power mobility devices
  • planning the frequency of on-site visits as part of the Medicare enrollment or re-enrollment process

As the OIG begins to implement its FY 2013 Work Plan, providers should continue to monitor what Medicare and Medicaid areas receive increased attention.  Additionally, providers should be proactive as the deadlines approach for implementation of parts of the ACA.