Overpayment Requests Continue to Confound Practices

Editor's note: We work hard to write about issues that will help physicians run their practices in a manner that is both prosperous and efficient, while still delivering quality patient care. And we are delighted when our readers let us know what they are thinking. This month we are excerpting an article from Michael Sacopulos, JD, on what practices should do if payers don't request overpayments and a slideshow from Steph Weber on the worst HIPAA fines of 2016. The articles have been edited for space and are followed by comments made by readers at PhysiciansPractice.com.

What if Payers Don't Request Overpayments?

Unless every email from CMS has mysteriously gotten stuck in your spam folder, you probably know that Medicare and Medicaid require providers to refund overpayments within 60 days of discovery. If you are not aware of this rule, please pause now and read this. Once you are done, do not pass go and do not attempt to collect $200. Instead, generate a credit balance report from your practice management system before the close of business today. Begin verifying and processing the refunds for valid Medicare and Medicaid overpayments immediately.

Although most practices are aware of the 60-day refund rule for government programs, many physicians ask me if there is a similar requirement for commercial, HMO, and PPO plans. The short answer is, yes. Once overpayments from these plans are discovered, a provider is required to refund them even if the payer does not request it.

The long answer is, when it comes to plans with which you have a written contract, you'll find that most agreements include a clause that outlines this requirement, along with the time period within which the practice must make the refund.

Kunak asks: "What's the risk involved if the refund was not paid?"

Dorothy responds: "Depends on your state and how active they are. There is something called an Escheat Law, which requires businesses that have money paid in excess of the charge to send it to the state. It is different in every state and some are more proactive than others in hunting the funds down. The state I am in requires even a penny to be sent to them or you could face a fine. How long you wait to send the money to the state also varies by state. [In our state] anything left on the books after five years has to be sent to the state. I have a spreadsheet by year where I keep records of overpays to both patients and insurance companies where refund checks have been returned. I also document in the record if a bad address and no valid phone number for patient and for insurance company that they returned the check and what they said. It is a pain to keep up with but I try."

Aja asks: "We have had several instances where the payer has refused a refund, even though we have provided them with the data that they have overpaid. We have even sent a check to them in which they have returned to us. How do we handle this situation?"

Toni says: "We have [faced] similar situations. I also wonder about a minimum amount. If there is only a small credit, say less than $5, are there any guidelines on that?"

Editor's Note: Can anyone help out Aja and Toni? Let us know in the comments section!

The Worst HIPAA-related Incidents of 2016

Last year, the U.S. Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) only levied six settlements against healthcare entities for HIPAA violations related to the improper handling and unauthorized exposure of patients' protected health information (PHI) and electronic PHI (ePHI). This year, though, has seen that number double with more than half of the settlements valued at greater than $1.5 million.

Here are the details of the worst HIPAA-related incidents of the year.
David responds: Two points jumped out at me: 1.) Why would anyone self-report a stolen laptop… and subject themselves to such ridiculous fines? 2.) It doesn't appear that any harm was done to patients in the vast majority of these cases. One can only hope that rules/regulations will become more reasonable at HHS with the new administration.
Anna Marie says: "All of these situations are unacceptable, but what I read about New York Presbyterian Hospital was frankly inhumane, and their fine should have been at least double what they received!”