What Is an Overpayment Really? Overpayment Investigations, Refunds, and False Claims Act Exposure (2024 Medicare and Medicaid Single Session)

The Medicare program is governed by voluminous statutes, regulations, and sub-regulatory guidance that potentially carry payment implications for various items and services. The federal Overpayments Statute (SSA § 1128J(d)) and its implementing regulations and CMS guidance impose certain obligations on providers and suppliers to affirmatively report and refund identified overpayments. Several significant federal court cases have drawn some important boundaries around what kinds of program rules and requirements potentially can result in Medicare overpayments. This presentation will explore risks and obligations under the federal Overpayments Statute and, derivatively, the FCA. The presentation will assume familiarity with the federal Overpayments Statute, regulations, and guidance. We will discuss recent case law and key concepts and considerations through overpayment scenarios and case studies.

• The CMS proposed rule abandoning the “reasonable diligence” standard and changing the definition of when a provider is deemed to have “identified” an overpayment under the Overpayment Statute

• Criteria for identifying Medicare “conditions of payment” capable of triggering overpayments, as distinct from “conditions of participation” and other program rules

• Supreme Court decisions, Kisor, Allina, SuperValu and Safeway, etc., that inform providers’ thinking about potential overpayments

• Federal court cases applying the Escobar “materiality” standard

• Practical strategies and real-life examples for resolving potential overpayment situations