If your practice accepts Medicare or Medicaid, the Supreme Court’s upholding of the Affordable Care Act last June includes stipulations responsible for even more regulations and administrative burdens.
Among the trickiest new rules are those aimed at identifying and preventing fraud as a means of cracking down on overpayment. Meanwhile, you continue suffering from the regulation migraine. What’s in it for you? Well, it’s time to make the most of your playing hand.
How Are You Affected?
The passing of the ACA expanded the scope of the False Claims Act (FCA), a federal law designed to help the government recover overpayments to its contractors and pursue fraudulent allegations.
If you receive a Medicare overpayment, you have 60 days to report and return the fee before possibly facing civil charges, even if the overpayment was erroneous. Of course, some say 60 days aren’t enough, given the complexities behind medical billing errors.
While it’s expected the government will draft additional regulations to address the FCA’s reach into the private practice arena, it’s important your office keeps an eye out for overpayments. We’ll help show you what needs to get done.
Monitoring Inconsistencies
Your first step is to buckle up. Designate a point person at your practice that will instill a process-oriented plan for staff members to spot and sideline overpayments before they become nuisances.
Also, if your practice management software has an alert system in place, use it to help you spot inconsistencies. Align any alerts with your and your point person’s email addresses if possible.
Your practice management system or EHR can also help ensure your practice is coding properly. You’re always a number away from an incorrect payment.
Lastly, if an overpayment is processed, report issues to your Medicare Administrative Contractors (MACs). If you establish a good practice-to-MAC relationship early on, it could help if enforcement of overpayment violations becomes more stringent in the future.
Overpayment Processes
There are typically three sources of overpayment: patient, payer, or administrative error. There are processes you can embark on to tackle both and nip the problem in the bud, provided they aren’t the result of a more complex white-collar infraction.
Patient overpayment:
- Notify the patient of the overpayment.
- Suggest a credit first.
- If the patient denies it, send a reimbursement check.
Payer overpayment:
- Call the carrier, ask about the incorrectly processed claim.
- If the payer confirms, have the payer reprocess the claim to show correct payment and ask them to send a request for returning overpayment.
- Attach overpayment to request and send it back to the address provided, or you may send it back to the claims department if no address was indicated.
Special cases:
- If the payer states they processed your claim correctly, continue investigating.
- A patient may have two insurance plans, and the second payer may have allowed and paid a higher amount than the primary carrier. A credit balance results.
- If this is the case, the patient’s balance needs to be adjusted to offset the credit. This is not actually an overpayment.
- If the second insurance carrier is privately purchased, the overpayment belongs to the patient.
- Return overpayment to the patient, either via check or practice credit.
Create a Compliance Plan
This is the probably most robust way to protect yourself against overpayment penalties. The ACA already requires a wide range of providers to establish compliance and ethics programs if they want to continue in the Medicare and Medicaid programs. The Office of the Inspector General’s (OIG) “Seven Fundamental Elements of an Effective Compliance Program” is an incredible place to start.
This is where we tease next week’s ACA piece, where we’ll detail the benefits of the OIG’s compliance plan and how you can use it to engage with your team.
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