Healthcare News & Insights

Your next compliance hurdle — avoiding reverse false claims

A new lawsuit could bring facilities some much needed clarity about how to avoid reverse false claims violations, a type of fraud that could open healthcare providers up to more penalties. 

467977083The Centers of Medicare & Medicaid Services (CMS) has devoted tons of resources to preventing fraudulent billing and collecting overpayments. Typically, healthcare providers only need to worry about ensuring their billing process accurately reflects the services provided in order to stay compliant with the False Claims Act (FCA).

But that alone won’t protect facilities from penalties for reverse false claim violations for not returning Medicare overpayments within a certain time frame.

Pitfalls of reverse false claims

Leslie Levinson, an attorney for healthcare practices, explains how reverse false claims came to be and how hospitals can protect themselves in an interview with FireceHealthcare.

When the Affordable Care Act (ACA) was implemented, the law had a provision that amended the FCA. Under the new provision, if an overpayment isn’t returned to CMS within 60 days of identification, it becomes an FCA issue. Failing to swiftly return the payment could then open a provider up to monetary penalties and disciplinary action from CMS.

As of now, the guidance CMS has released on the subject of reverse false claims hasn’t been made final, and contains several gaps in information.

One item touched on, but not fully explained, is that the 60-day countdown begins when an overpayment is identified. And if the provider suspects they may have received an overpayment, it’s required to investigate further or risk committing a violation of the FCA. This is concerning because it puts a heavy burden on facilities to constantly evaluate their reimbursement for possible overpayments.

Develop compliance plan

Levinson also believes the law may potentially result in more whistleblower complaints and provoke new kinds of whistleblower lawsuits against hospitals.

Recently the Department of Justice intervened in a lawsuit involving Continuum Health Partners, Inc., which allegedly withheld Medicare overpayments too long after identifying them. Levinson believes the lawsuit is significant because it may provide some clarity about when an overpayment is officially identified, as well as push CMS to finalize regulations in this area.

In the meantime, Levinson recommends that providers develop their compliance plans so that they “aren’t only tailored to the provider, but also include all appropriate policies and procedures for monitoring payments. If there’s been an inkling of a potential overpayment, there should be a mechanism for investigating and dealing with it.”

Providers also should be in contact with legal counsel when they think an overpayment was made, and ensure their investigations into overpayments are thorough and well-documented.


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