Recent Case Highlights Need for Providers to Comply with the 60-Day Overpayment Rule

October 16, 2017 Advisory

On October 13, 2017, the United States Department of Justice ("DOJ") announced a $448,821.58 settlement with First Coast Cardiovascular Institute, PA ("First Coast"), a Florida provider of clinical and laboratory services, to resolve allegations that First Coast unlawfully retained $175,000 in overpayments. This settlement sends a clear message to the health care community that the federal government is serious about pursuing providers that fail to report and refund overpayments within 60 days, regardless of the unintentional nature of the underlying conduct that resulted in the overpayment.

The government's complaint alleged that First Coast overbilled federal health care programs. However, instead of alleging that these overpayments resulted from improperly billing a particular service or CPT code, the government stated that the provider violated the federal False Claims Act by retaining certain credit balances that it received and failing to return them to the applicable federal payors within 60 days of their discovery. These credit balances were caused for many different reasons, including overpayments and duplicate payments received from insurers, coordination of benefit conflicts, improper collection of upfront payments, or change corrections made to claims after payments were made. In fact, credit balances are common in the health care industry because payment issues often take a long time to be resolved between providers, payors, and patients. In the complaint, the government explained that "over-billing can occur for a variety of reasons, even innocently- for example, where a patient has two different insurances, sometimes both are billed as a primary insurer, or where an insurer is inadvertently billed twice for the same procedure, and so forth. This is a normal occurrence in the health care field."

To read the entire advisory, please click the PDF link below.