Hospital Compliance Officer: Monitor Your Medicare Revenues

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By Eric Topor

A spike in a provider’s Medicare revenue could trigger an obligation to investigate and quickly repay mistaken claims under the 60-day overpayment rule.

A spike in Medicare revenue could be considered “credible information” that overpayments have been received and could start the clock on a required repayment within 60 days, Steve Hinkle, vice president and chief compliance officer for Nashville-based Ardent Health Services, said March 30. The 60-day rule generally requires a health-care provider to return an identified overpayment within 60 days, and recent court precedent has attached False Claims Act liability to providers who failed to do so.

Hinkle, speaking at an American Health Lawyers Association conference in Baltimore, pointed out that a provider’s accounting department and other departments likely already are monitoring Medicare revenue streams. Hinkle said a compliance officer who becomes aware of a Medicare revenue spike needs “to dig in [to it] and find out why” it’s occurring and whether it is the result of an overpayment.

Hinkle noted that a Medicare revenue spike could be due to legitimate reasons like an increase in patient volume but could also be the result of a billing coder repeatedly coding claims at improperly high rates.

Proactive Compliance

Robert Roth, a partner with Hooper Lundy & Bookman PC in Washington, noted that the 60-day rule requires both “proactive and reactive compliance.” Roth pointed to a provider’s potential exposure to FCA liability as a harsh result of a compliance misstep given the somewhat nebulous proactive compliance requirement, which isn’t defined in the rule. Roth is a Bloomberg BNA advisory board member.

Hinkle noted that the Centers for Medicare & Medicaid Services makes allowances for how sophisticated and rigorous a compliance program needs to be based on the size and sophistication of a provider. Hinkle said a physician practice with a few physicians or only one won’t be held to the same standard as a larger practice but recommended that “every practice have some sort of compliance program.”

Even for very small providers, Hinkle said it is important to be able to point to some type of documentation to show the CMS what steps are being taken to identify overpayments. Hinkle recommended that providers who outsource billing to ensure the billing contractor has a compliance program in place to catch potential overpayments.

Negotiate on Overpayments?

Roth said providers take particular umbrage when claims are deemed to be overpayments for “technicalities,” such as lack of documentation, or failure to show medical necessity. Roth said a lack of adequate documentation could simply be a provider’s failure to retain documents until the time the claim was reviewed, sometimes years later.

Roth said these instances result in “financial harm to the provider,” which is forced to repay a claim for services that were actually provided to a Medicare beneficiary. Roth wondered whether in these cases a provider or its counsel “could have a dialogue with the government to see if there is another solution,” such as partial repayment.

To contact the reporter on this story: Eric Topor in Washington at

To contact the editor responsible for this story: Peyton Sturges at

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