Step out of the compliance gray area
Step out of the compliance gray area
Never report overbilling without legal counsel
(Editor's note: The following series of questions were answered by Roy Snell, Senior Manager of Health Care Regulatory Consulting at Deloitte & Touche in New York City. Snell also currently serves as president of the Health Care Compliance Association in Philadelphia.)
Question: When is it appropriate to return an overpayment to your fiscal intermediary and when must it be reported directly to federal authorities?
Answer: You should return any overpayment that you receive when you discover it.
Whether you should report it to the government depends on several factors: the dollar amount and the nature of the problem and "whether it was a pattern of overpayment or a random occurrence." Your legal counsel can help you make that determination. Consulting your legal counsel is an absolute rule of thumb.
Question: Should you only report large amounts?
Answer: There is no specific figure above which you should report. It depends on many factors. You may have a contract with a payer that requires you to report an overpayment over a certain amount, but this situation is rare. Consult your legal counsel.
Question: Should you report only patterns of overpayments or single instances?
Answer: You need to consider whether you have determined if it was an innocent mistake or an intentional overbilling. You would be more likely to report an intentional overbilling than a simple honest mistake.
An example of a simple mistake would be a misprinted CPT code on a superbill or charge ticket. An intentional mistake would be someone intentionally billing for services that were performed while he or she was out of town.
Question: If you discover instances of intentional overbilling, do you have to show that you have taken action to stop the practice?
Answer: If you discover a practice of overbilling, if it's a gray area, you may not stop the practice until you have thoroughly researched the regulations and the documentation and the claims that went out. If it's a black-and-white issue, you would most likely stop the billing while you checked the regulations, the documentation, and the claims.
Question: Who should overpayments be reported to?
Answer: If you've determined that it's big enough to be reported and if it doesn't involve Medicare, you probably would not report it to the Office of Inspector General (OIG), which covers federal programs. If it's a state program such as Medicaid, you would probably report it to the state attorney general's office.
Once again, you should review all of your decisions with your legal counsel. Above all, don't make a move like this without counsel.
Question: Should you be more concerned about overpayments by one payer as opposed to another?
Answer: Because of the Health Insurance Portability and Accountability Act of 1996, you should be concerned about all payments equally.
Question: What is the mechanism for self-reporting?
Answer: It depends on which payer you are reporting it to. It's going to be different for every commercial payer. Generally speaking, the commercials, the carriers, the attorney general, and the OIG usually have a fraud unit to report overpayments to. Your legal counsel should make the first contact.
But when you first find a problem, you must be very careful to thoroughly investigate and prove beyond a shadow of a doubt that the problem really exists. Don't panic. Do a thorough investigation.
A lot of issues that are brought to your attention later prove to be a non-issue after the documentation, the regulations, and the bills are thoroughly reviewed. Dot your I's and cross your T's before you even ask the question of whether to refund. Your first reaction should be to thoroughly investigate and check lots of resources before you act.
[Editor's note: The Health Care Compliance Association can be reached at (888) 580-8373.]
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