The Social Security Act requires provider’s report any Medicare overpayment. A failure to do so can result in more than just a need to pay the government back, it could escalate to criminal charges. But what happens if the government makes a mistake? How do these cases move forward and what options do providers have if they disagree with the government’s findings?
There are options.
In a recent example, the Office of the Inspector General (OIG) flagged a New York provider because they had received a high rate of reimbursement compared to their peers. The government moved forward with an audit that spanned two years, from 2018 through 2020. From this period, the auditors pulled 100 sample days for examination. The auditors state that none of the sample days complied with Medicare billing requirements. Noted issues included:
- Provider issues. The auditor reported that in some of the reviewed charges psychotherapy services were not provided by a therapist licensed in the state.
- Missing signature. There were instances the treating physician did not sign off on the patient’s treatment.
- Lack of plan. In still other cases, patients’ files did not contain a treatment plan.
Based on these and other findings, the OIG concluded the provider received over $1 million in Medicare overpayment.
What comes next?
The OIG has called on the provider not only to repay the $1.1 million in alleged overpayments but to also review all payments from the last 60 days for any additional overpayment. The OIG has also called on the provider to take steps to ensure their therapists comply with Medicare billing rules. This includes reviewing and updating the practices, policies and procedures as well as providing their therapists with additional training for billing.
When faced with these findings, the provider agreed to review its procedures and training methods but disagreed with the OIG’s findings calling them “grossly overbroad.”
Did the provider’s response help?
The OIG reviewed the provider’s response and agreed to reduce the number of deficiencies. This is just one option for providers in this situation. Providers can also go through an appeal process to further challenge the governments findings.
Attorney John Rivas is responsible for this communication