Practice Concepts, Inc.
Challenges To Practice Management
Providing Updates On Challenges To Physician Practice Management.
The team at Practice Concepts are experts at helping physician practices, whether independent or hospital-owned, overcome challenges to successful practice management.This page highlights either new or important issues that can be addressed with the assistance of Practice Concepts.
New Risks Of Inadvertently Breaking Federal Laws
Rules finalized by CMS now make a regular practice potentially guilty of the federal False Claims Act for failing to send back an overpayment to Medicare or Medicaid you did not even know was due. The “clarified” rule states that a person must send back an overpayment within 60 days of being identified. The "overpayment" has been “identified” when "a person has, or should have through the exercise of reasonable diligence, determined that the person has received and overpayment….”. Reasonable diligence requires providers to have ongoing, proactive compliance activities to monitor claims and take action when potential refunds are identified. The real concern of this rule is how "overpayments" are defined. CMS had indicated that any monies inappropriately paid are overpayments. For example, if a physician bills a 99214 office visit and CMS later determines it should have been a 99213 code, the excess amount is considered an overpayment. If not identified by the practice and refunded, then the practice potentially is liable for criminal penalties. Legal counsel should be used for understanding the legal ramifications.
What Should A Practice Do?
The burden is now on the practice to find and refund overpayments, so not knowing about a refund is not a defense. All practices must now have a regular documented process to identify overpayments. There must be regular auditing of a practice’s billing records with documentation of steps taken.