Ophthalmology and Optometry Coding Alert

Question: Our MAC says we must return any overpayments to federal health programs within 60 days. Does that cover all payers or just Medicare?

Codify Subscriber

Answer: CMS issued a rule last year setting a 60-day limit on returning overpayments to federal agencies, which refers to Medicare, Medicaid, Tricare, and any other federally-funded insurer, but could also extend to others. The important thing to remember is that while the rule might seem simple, it actually represents some big changes related to compliance – and a practice that fails to comply might face huge penalties.

The reasoning:  Every practice occasionally handles overpayments, but the 60-day rule is designed to help practices identify systemic overpayment problems. Federal officials expect providers to sniff out coding or billing issues, and to move swiftly to address those issues. Any overpayments you discover should then be refunded within the 60-day window, and the underlying problem fixed to avoid future overpayments.

Dealing with any overpayments quickly is important because if federal agencies discover that you knew about overpayments and failed to repay them promptly, you could be looking at penalties related to the False Claims Act or the Civil Monetary Penalties Law. In the worst case scenario, your practice could be excluded from all federal healthcare programs.

It’s no fun to identify an overpayment, especially if it turns out to be part of a larger issue that requires work to fix. But once you do identify the issue, it’s in your interest to correct it, both to avoid penalties and because it’s the right thing to do.