Lookback Period for Medicare/Medicaid Overpayments

In February of 2016, the Centers for Medicare & Medicaid Services (CMS) added a provision to the Affordable Care Act with the goal of reducing fraudulent overpayments in relation to Medicare and Medicaid health plans. This provision introduced three major changes: identification of overpayments, the 60-day rule, and lookback periods.

What is the lookback period for Medicare overpayments?

Under current ruling, the lookback period for Medicare credit balances is six years. According to CMS.gov, “Overpayments must be reported and returned only if a person identifies the overpayment within six years of the date the overpayment was received.” This lookback period represents how far back credit balances can be reviewed to identify and return overpayments. This also means Medicare contractors may reopen claims up to six years old to report and return overpayments.

What is the 60-day rule?

The 60-day rule defines the amount of time in which you must report and return overpayments. Beginning when the overpayment is discovered, there is a 60-day period during which the overpayment must be returned and reported. The 60-day clock starts when either reasonable diligence is completed or on the day you receive credible information of a potential overpayment, and there was indeed an overpayment made.

What does CMS consider “identification” of overpayments?

In a fact-sheet published to CMS.gov, the identification of an overpayment is defined as, “when a person has or should have, through the exercise of reasonable diligence, determined that the person has received an overpayment and quantified the amount of the overpayment.”

How are Medicare overpayments identified?

Medicare overpayments can be discovered in various ways, not least common of which being an MAC/RAC audit. These are audits conducted by Medicare contractors to identify any overpayments and enforce compliance with CMS rules.

Outside of audits, healthcare providers who are following strict protocols & procedures for the handling of government credit balances will be able to identify and resolve Medicare credits within the 60-day timeframe set forth by CMS. Once you begin to understand the root-causes of overpayments, with the assistance of a credit balance resolution vendor like Crossroads Health, you can get ahead of this problem and avoid compliance risks.

How do I resolve Medicare overpayments?

The update requires that processes and procedures be implemented in order to report upon and return payments appropriately, such as using working with a credit balance vendor to ensure the proper handling ofMedicare/Medicaid overpayments. If you do not have said policies & procedures in place for the identification, resolution and reporting of Medicare credit balances, consider contacting Crossroads Health – the complete credit balance resolution service for healthcare providers.

How to report and return Medicare overpayments

Self-identified overpayments must be disclosed and promptly handled. In CMS’ words, “suppliers must use an applicable claims adjustment, credit balance, self-reported refund, or another appropriate process to satisfy the obligation to report and return overpayments.” Also, “if a health care provider or supplier 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 (OIG), the provider or supplier is considered to be in compliance with the provisions of this rule.”