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CMS 60-Day Repayment Final Rule

CMS issued its final rule for the 60-day repayment regulation on February 12, 2016. The final rule requires the timely refund of any overpayment identified by a provider. The effective date of the final rule is March 14, 2016.

Most health care attorneys believe the final rule is a fair approach to this issue. The various health care business groups will monitor how each Medicare contractor implements the final rule.

Highlights of the final rule are as follows: 

  1. Any Medicare payment received or retained by a provider organization that they are not entitled to is an overpayment. This could be receiving a payment in error from a Medicare contractor.
  2. The 60-day period starts after a provider has identified and quantified the overpayment amount using reasonable due diligence.
  3. To exercise reasonable due diligence you need to conduct proactive and reactive investigations.
  4. Most investigations are expected to be complete in 8 (6 months to investigate and quantify the amount, plus the 60-day repayment period).
  5. If CMS determines that no reasonable due diligence has taken place, then the 60-day period starts at the date of identification.
  6. If a repayment issue is based on a systemic problem, the provider has to go back 6 years to calculate the repayment amount. The proposed rule called for a 10-year look back period, so the Final Rule was less punitive.
  7. All report and refund forms plus procedures should be used by the Medicare contractor who made the overpayment to the provider.
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