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”). Specifically, with respect to the meaning of “identification” of overpayment, CMS proposes to eliminate the “reasonable diligence” (or traditional negligence) standard and replace it with the False Claims Act’s (“FCA’s”) standard of “knowing” and “knowingly” (i.e., reckless disregard or deliberate ignorance of a potential overpayment).
Under the current Overpayment Rule, a person who has received an overpayment must report and return it within 60 days of discovery to the Secretary, the State, an intermediary, a carrier, or a contractor, as appropriate, and must also notify that entity in writing of the reason for the overpayment. As currently written, the Overpayment Rule holds that a person has identified an overpayment when they have determined, or should have determined through the exercise of reasonable diligence, that they have received an overpayment.
UnitedHealthcare Litigation
UnitedHealthcare challenged the current Overpayment Rule in litigation.[1] One of its main arguments was that incorporating a negligence standard through the definition of “identification”, i.e., requiring Medicare Advantage Organizations (“MAOs”) to use “reasonable diligence” in identifying overpayments, conflicted with the knowledge standard in the FCA and improperly created liability for mere...
BRENTWOOD, Tenn. (WSMV) - A Tennessee doctor has pleaded guilty to committing millions of dollars’ worth of Medicare fraud through her Brentwood optometry practice. Helen Boerman, 48, pleaded guilt...