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CMS Proposes to Amend Overpayment Rule, Remove Potential Overpayment and False Claims Act Liability for Mere Negligence

Healthcare Law Blog

The Centers for Medicare and Medicaid Services (“CMS”) has issued a proposed rule which would amend the existing regulations for reporting and returning identified overpayments (the “Proposed Rule”). UnitedHealthcare challenged the current Overpayment Rule in litigation. [1] UnitedHealthcare Litigation. The Proposed Rule.

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CMS Proposes to Drastically Change Overpayment Refund Rule

Hall Render

On December 27, 2022, the Centers for Medicare & Medicaid Services (“CMS”) published a proposed rule that could potentially have a significant impact on enrollees’ obligations under the “60-day” overpayment rule. In fact, claims reviews to quantify an overpayment is a time-consuming effort and the six-month period is necessary.

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Healthcare Compliance Risks with Urine Drug Testing Overpayments 

YouCompli

There has been significant enforcement over the last couple years relating to overpayments for UDT. The overpayment rate for definitive drug testing for 22 or more drug classes was over 71%. Review at-risk payments made to at-risk providers during and after the OIG’s audit period and recover any overpayments.

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New York Medicaid Providers Now Have Two Pathways to Self-Disclose Overpayments to the Office of the Medicaid Inspector General

Healthcare Law Blog

On August 21, 2023, the New York State Office of the Medicaid Inspector General (OMIG) announced updates to the Medicaid overpayment self-disclosure program, which now includes an abbreviated process for reporting and explaining overpayments that are considered routine or transactional in nature and have been already voided and adjusted.

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CMS Publishes RADV Audit Methodology and Intent to Recover Overpayments

Hall Render

billion in overpayments from MAOs for payment years 2011 through 2017. Further, CMS estimates that beginning with payment year 2018, it will identify approximately $479 million per audit year in overpayments to MAOs. Background RADV audits are the main tool that CMS uses to correct overpayments made to MAOs.

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CMS Issues Long-Awaited Medicare Advantage RADV Final Rule

Healthcare Law Blog

Likewise CMS cited its fiduciary duty to protect taxpayer dollars from overpayments and its fiduciary responsibility to recover funds due to the Medicare Trust Funds. case number 18-5326 , which reinstated CMS’s Overpayment Rule for MA organizations. The Court of Appeals reversed and reinstated the Overpayment Rule.

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California pharmacies will no longer be required to pay back the state under its new reimbursement methodology

Natalia Mazina

See a related blog post. This lead to overpayments to pharmacies. Back in 2017, the California Department of Healthcare Services (DHCS) approved a new methodology – National Average Drug Acquisition Cost (NADAC) – for reimbursing pharmacies for their drug cost. NADAC prices significantly reduced pharmacy reimbursements.