Congratulations! You have reached the final step in understanding the core elements of OIG compliance. It is time to put together all the pieces to create a process that will fix what is broken. You must never let your compliance-related activities be verbal only. You need to keep documented proof of every investigation, report, and…
Oops, your level of membership doesn’t include access to these advanced materials. They are reserved for members working directly with our OIG compliance specialists. Please reach out to the HelpDesk to learn more about accessing these materials.
Click here to learn more.
Reporting Overpayments
CMS relies on the existing voluntary refund process defined in the Medicare Financial Management Manual, as well as claims adjustments, credit balances, and self-reported refunds to report and return overpayments. It is important to include the following information in your report:
-
- The health insurance claim number
- How the error was discovered
- Description of the corrective action plan implemented to ensure the error does not occur again
- Whether the provider or supplier has a corporate integrity agreement
- The timeframe and the total amount of the refund for the period during which the problem that warranted the refund existed
- The method used to determine the overpayment
- The reason for the refund
According to CMS, the reasons most commonly given for overpayments by providers include:
-
- An incorrect service date
- A duplicate payment
- An incorrect CPT code
- Insufficient documentation
- Lack of medical necessity
This information pertains to CMS and Medicare; third-party payers usually have their own policies for reporting overpayment. Your compliance program should include details for all of the third-party payers with whom you work. Implementing an investigative policy and reporting procedure helps your office comply with these guidelines.
We encourage you to have your staff review the following tutorial titled Overpayments & Refund Requests. This quick tutorial provides an overview of overpayments and what a clinic should do if they receive a refund request from a payer. A well-informed staff will support the compliance officer in building a compliant practice.
Identifying the Alleged Non-Compliance One of the most common offenses in clinics is the mismanagement of overpayments. An overpayment is not a payer’s way of saying, ‘well done, you deserve a bonus.’ The same applies to patient overpayments – when the patient pays more than the patient portion assigned to the claim by the payer….
Oops, your level of membership doesn’t include access to these advanced materials. They are reserved for members working directly with our OIG compliance specialists. Please reach out to the HelpDesk to learn more about accessing these materials.
Click here to learn more.
This tutorial will walk you through the steps of a compliant incident reporting process. The investigation process requires the clinic to ask questions, gather data and assess risk. This leads to documenting the offense, assigning corrective actions and implementing training. Use this tutorial to assess your current process for incident reporting and take note of…
Oops, your level of membership doesn’t include access to these advanced materials. They are reserved for members working directly with our OIG compliance specialists. Please reach out to the HelpDesk to learn more about accessing these materials.
Click here to learn more.
Do Not Ignore Offenses It is important that a clinic not only complete thorough audits but also prepare corrective actions if warranted. In some cases, the corrective action requires additional reporting to authorities and/or immediate legal action. An offense can be as simple as an employee not abiding by the code of conduct. And it…
Oops, your level of membership doesn’t include access to these advanced materials. They are reserved for members working directly with our OIG compliance specialists. Please reach out to the HelpDesk to learn more about accessing these materials.
Click here to learn more.
Audits allow the compliance officer to keep a finger on the pulse when it comes to compliance activities. At this point of the OIG implementation training, you will learn about self-auditing by shadowing the KMC University Specialist as they use a variety of auditing tools. Guidance on the Auditing Process For you and the Specialist…
Oops, your level of membership doesn’t include access to these advanced materials. They are reserved for members working directly with our OIG compliance specialists. Please reach out to the HelpDesk to learn more about accessing these materials.
Click here to learn more.