Overpayment and Refund Process

-->July 28, 2017Magazine

By: Mark Weinstein, Vice President of Operations

Government carrier overpayment requirements are a foundation of Medac operational compliance. For simplicity purposes, the Medicare rules will be referenced.

The Medicare statute defines an overpayment as any funds received by a health care entity that are in excess of amounts to be paid under Medicare statutes and regulations. Overpayments may be attributed to various operational and payment errors, including non-covered services, duplication and eligibility issues.

Identifying overpayments is the critical component of the Medicare 60-day Refund Rule. An overpayment is considered “identified” when a person has actual knowledge of the overpayment or acts in “reckless disregard or deliberate ignorance” of the existence of the overpayment.

The Medac KAM anesthesia billing software flags overpayments when carrier’s reimbursement is higher than the expected rate in our system. At that point, the case is reviewed, and if deemed a valid overpayment, the case is referred to the Medac Refund Department for processing.

In addition, the Refund Department reviews the Credit Balance report and addresses other overpayments and processes these in accordance with carrier requirements. Utilizing the Overpayment and Credit Balance Reports, Medac’s technology can identify all government and commercial carrier overpayments.

The Refund Department validates and confirms the overpayment and processes a refund in accordance with the government carrier refund requirements. Refunds are processed by executing a check to the carrier, or according to the carrier’s required alternative process, such as notification and carrier recoupment. When carriers recoup an overpayment, the carrier lowers the paid amount for cases on a current remittance.

Medac’s credit balance process effectively addresses the 60-day government carrier rule, and ensures all credit balances from other carriers are handled as promptly and efficiently as possible. Government credit balances are always our first priority when we submit our refund file to our clients. Quick client turn-around is essential for both Medac and our client to be compliant with the 60-day rule.