Court Decides “Absurd” Is Worse than “Potentially Unworkable” When Interpreting 60-Day Repayment Rule
By Kelly A. Briganti, Editorial Director, G2 Intelligence A federal district court has weighed in on the meaning of “identified” for purposes of determining when Medicare and Medicaid overpayments must be returned to avoid violating the False Claims Act. That court resolved the debate about when the Affordable Care Act’s 60-day deadline for returning overpayments begins to run, explaining the deadline is triggered when providers are on notice that they may have received overpayments—not after they’ve determined with certainty the precise amount of the overpayment. After a health insurance company’s “software glitch” caused multiple hospitals in the same health system to submit improper Medicaid claims, an internal investigation yielded a list of 900 potential Medicaid overpayments. But it wasn’t until after the government filed a Civil Investigative Demand and two years had passed since the original list was generated that the health system repaid hundreds of overpayments. The federal and New York governments intervened in a whistleblower lawsuit, arguing the provider violated the False Claims Act by “intentionally or recklessly” failing to timely repay overpayments. The defendant sought to dismiss the lawsuit arguing that the employee’s list was only notice of potentially improper claims. Because further investigation was needed to […]
By Kelly A. Briganti, Editorial Director, G2 Intelligence
A federal district court has weighed in on the meaning of "identified" for purposes of determining when Medicare and Medicaid overpayments must be returned to avoid violating the False Claims Act. That court resolved the debate about when the Affordable Care Act's 60-day deadline for returning overpayments begins to run, explaining the deadline is triggered when providers are on notice that they may have received overpayments—not after they've determined with certainty the precise amount of the overpayment.
After a health insurance company's "software glitch" caused multiple hospitals in the same health system to submit improper Medicaid claims, an internal investigation yielded a list of 900 potential Medicaid overpayments. But it wasn't until after the government filed a Civil Investigative Demand and two years had passed since the original list was generated that the health system repaid hundreds of overpayments. The federal and New York governments intervened in a whistleblower lawsuit, arguing the provider violated the False Claims Act by "intentionally or recklessly" failing to timely repay overpayments. The defendant sought to dismiss the lawsuit arguing that the employee's list was only notice of potentially improper claims. Because further investigation was needed to determine which claims actually were overpaid, the health system argued the list didn't "identify" overpayments or trigger the 60-day deadline. The court disagreed with the health system explaining that waiting to trigger the 60-day deadline until providers "determine[d] conclusively the precise amount owed to the Government" created "a perverse incentive to delay learning the amount due and relegating the sixty-day period to merely the time within which they would have to cut the check."
"[W]hile the Government's interpretation would impose a stringent—and, in certain cases, potentially unworkable—burden on providers, Defendants' interpretation would produce absurd results," the court concluded.
For more information about this ruling, see the next issue of G2 Compliance Advisor.
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