Medical Billing News

The 60-Day Rule: Understanding the New Requirements for Overpayments

04/19/2016

The Centers for Medicare & Medicaid (CMS) services has done its fair share of confusing people, but a proposed rule issued back in February 2012, under Section 6402 of the Affordable Care Act, may take the cake as its most cryptic communique ever.

The rule required providers and medical billing teams who discover an overpayment to refund it within 60 days, or else be considered to have made a "false claim." In the context of the rule, an "overpayment" referred any funds received or retained under the Medicare or Medicaid programs to which the recipient was not entitled – dollar amounts be damned – even if the claim was not known to be false at the time of submission.

Hypothetically, the proposed rule could put a provider at the mercy of the False Claims Act for accepting just a few dollars too many on a given reimbursement (even if it resulted from Medicaid’s or Medicare’s error). But the what-if-it’s-just-a-few-pennies issue pales in comparison to the larger question posed by the proposed rule: Within 60 days of what, exactly?

The CMS took its time to clarify the answer, finally issuing guidance (as we’ll explain below) in February 2016. But even before the CMS did so, providers were held to full compliance with the requirement – whether they understood it or not.

Now that the Final Rule has (finally) been issued, we’re here to help you understand it. Here’s what you need to know.

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