Even the Smallest of Providers Needs Compliance Cover Under the 60-Day Rule


An unexpected spike in Medicare reimbursement, if missed by a provider, could be enough for federal officials to conclude it wasn’t doing enough to spot and refund overpayments.

Steve Hinkle, vice president and chief compliance officer for Nashville-based Ardent Health Services, said even a single physician practice needs to have “some sort of compliance program” in place to identify potential Medicare overpayments. 

Hinkle, speaking at an American Health Lawyers Association conference in Baltimore, said the 60-day rule’s requirement for providers to have both proactive and reactive compliance programs applies to small providers, too. Hinkle said though that the Centers for Medicare & Medicaid Services makes allowances for the sophistication of a provider’s compliance program based on provider size.

The 60-day rule generally requires providers to return Medicare overpayments within 60 days of identifying an overpayment. That 60-day clock can start to run when a provider suspects or should’ve suspected a potential overpayment.

At least one court has ruled that a failure to adhere to the 60-day rule’s requirements can result in an overpayment transforming into a false claim, including the triple damages and monetary penalty provisions nested in the False Claims Act.

The 60-day rule’s relatively tight investigation and repayment timeline, coupled with the possibility of FCA liability exposure makes having some type of good faith compliance program all the more important for small providers who can’t necessarily whether the years and expense of FCA litigation. 

Hinkle said having at least some type of documentation to show the CMS in the event of a suspected overpayment is important. One element of liability under the FCA is intent, and a good faith compliance effort, even if unsuccessful, might be the difference between an overpayment staying just an overpayment, and not becoming a false claim.

Hinkle also said that small providers who outsource their billing to third-party vendor should make sure those vendors have some type of compliance procedures in place to identify potential overpayments. 

To read more on 60-day rule compliance challenges, go to the full story here.  

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