Oregon Oregon Health Authority, Health Systems Division: Medical Assistance Programs

Rule Rule 410-120-1397
Recovery of Overpayments to Providers — Recoupments and Refunds

(1)

The Authority requires Providers to submit true, accurate, and complete claims or encounters. The Authority treats the submission of a claim or encounter, whether on paper or electronically, as certification by the Provider of the following: “This is to certify that the foregoing information is true, accurate, and complete. I understand that payment of this claim or encounter will be from federal and state funds, and that any falsification or concealment of a material fact maybe prosecuted under federal and state laws.”

(2)

Authority staff or a designee may review or audit a claim before or after payment for assurance that the specific care, item or service was provided in accordance with the Authority rules and policies, the terms applicable to the agreement or contract and the generally accepted standards of a Provider’s field of practice or specialty:

(a)

“Designee” for the purposes of these rules includes, but is not limited to, a medical, behavioral, drug or dental utilization and review or a post-payment review contractor;

(b)

“Claim” for the purposes of these rules includes requests for payment under a Provider enrollment agreement or contract, whether submitted as a claim or invoice or other method for requesting payment authorized by administrative rule, and may include encounter data.

(3)

The Authority may deny payment or may deem payments subject to recovery as an Overpayment if a review or audit determines the care, item, drug or service was not provided in accordance with Authority policy and rules applicable agreement, intergovernmental agreement or contract, including but not limited to the reasons identified in section (5) of this rule. Related Provider and Hospital billings will also be denied or subject to recovery.

(4)

If a Provider determines that a submitted claim or encounter is incorrect, the Provider is obligated to submit an Individual Adjustment Request and refund the amount of the Overpayment, if any, consistent with the requirements of OAR 410-120-1280 (Billing). When the Provider determines that an Overpayment has been made, the Provider must notify and reimburse the Authority immediately, following one of the reimbursement procedures described below:

(a)

Submitting a Medicaid adjustment form (DMAP 1036-Individual Adjustment Request) will result in an offset of future payments. It is not necessary to refund with a check if an offset of future payments is adequate to repay the amount of the Overpayment; or

(b)

Providers preferring to make a refund by check must attach a copy of the remittance statement page indicating the Overpayment information, except as provided by subsection (c) of this section. If the Overpayment involves an insurance payment or another Third Party Resource, Providers will attach a copy of the remittance statement from the insurance payer:

(A)

Refund checks not involving Third Party Resource payments will be made payable to Division Receipting — Checks in Salem;

(B)

Refunds involving Third Party Resource payments will be made payable and submitted to the Division Receipting — MPR Checks in Salem;

(c)

Providers making a refund by check based on audit or post-payment review will follow the reimbursement procedures described in the Overpayment notice or order in the audit or on post-payment review, if specified.

(5)

The Authority may determine, as a result of review or other information, that a payment should be denied or that an Overpayment has been made to a Provider, which indicates that a Provider may have submitted claims or encounters, or received payment to which the Provider is not properly entitled. Such payment denial or Overpayment determinations may be based on, but not limited to, the following grounds:

(a)

The Authority paid the Provider an amount in excess of the amount authorized under the state plan or Authority rule, agreement or contract;

(b)

A third party paid the Provider for services (or a portion thereof) previously paid by the Authority;

(c)

The Authority paid the Provider for care, items, drugs or services that the Provider did not perform or provide;

(d)

The Authority paid for claims submitted by a data processing agent for whom a written Provider or Billing Agent/Billing Service agreement or other applicable contract or agreement was not on file at the time of submission;

(e)

The Authority paid for care, items, drugs or services and later determined they were not part of the client’s benefit package;

(f)

Coding, processing submission or data entry errors;

(g)

The care, items, drugs or service was not provided in accordance with Authority rules or does not meet the criteria for quality of care, item, drug or service, or medical appropriateness of the care, item, drug, service or payment;

(h)

The Authority paid the Provider for care, items, drugs or services, when the Provider did not comply with Authority rules and requirements for reimbursement.

(6)

Prior to identifying an Overpayment, the Authority or designee may contact the Provider for the purpose of providing preliminary information and requesting additional documentation. Provider must provide the requested documentation within the time frames requested.

(7)

When an Overpayment is identified, The Authority will notify the Provider in writing, as to the nature of the discrepancy, the method of computing the dollar amount of the Overpayment, and any further action that the Authority may take in the matter:

(a)

The Authority notice may require the Provider to submit applicable documentation for review prior to requesting an appeal from the Authority, and may impose reasonable time limits for when such documentation must be provided in order to be considered by the Authority.

(b)

The Provider may appeal a Authority notice of Overpayment in the manner provided in OAR 410-120-1560 (Provider Appeals).

(8)

The Authority may recover Overpayments made to a Provider by direct reimbursement, offset, civil action, or other actions authorized by law:

(a)

The Provider must make a direct reimbursement to the Authority within thirty (30) calendar days from the date of the notice of the Overpayment, unless other regulations apply;

(b)

The Authority may grant the Provider an additional period of time to reimburse the Authority upon written request made within thirty (30) calendar days from the date of the notice of Overpayment if the Provider provides a statement of facts and reasons sufficient to show that repayment of the Overpayment amount should be delayed pending appeal because:

(i)

The Provider will suffer irreparable injury if the Overpayment repayment is not delayed;

(ii)

There is a plausible reason to believe that the overpayment is not correct or is less than the amount in the notice, and the Provider has timely filed an appeal of the Overpayment, or that Provider accepts the amount of the Overpayment but is requesting to make repayment over a period of time;

(iii)

A proposed method for assuring that the amount of the Overpayment can be repaid when due with interest, including but not limited to a bond, irrevocable letter of credit or other undertaking, or a repayment plan for making payments including interest over a period of time.

(iv)

Granting the delay will not result in substantial public harm;

(v)

Affidavits containing evidence relied upon in support of the request for stay:

(vi)

The Authority may consider all information in the record of the Overpayment determination, including Provider cooperation with timely provision of documentation, in addition to the information supplied in Provider’s request. If Provider requests a repayment plan, the Authority may require conditions acceptable to the Authority before agreeing to a repayment plan. The Authority must issue an order granting or denying a repayment delay request within thirty (30) calendar days after receiving it.

(c)

Except as otherwise provided in subsection (b) a request for a hearing or administrative review does not change the date the repayment of the Overpayment is due, and if the outcome of the appeal reduces the amount of the Overpayment, that amount previously paid by the Provider in response to the notice of Overpayment will be refunded to the Provider;

(d)

The Authority may withhold payment on pending claims and on subsequently received claims for the amount of the overpayment when Overpayments are not paid as a result of Section (7)(a);

(e)

The Authority may file a civil action in the appropriate Court and exercise all other civil remedies available to the Authority in order to recover the amount of an overpayment.

(9)

In addition to any overpayment, the Authority may impose a Sanction on the Provider in connection with the actions that resulted in the overpayment. the Authority may, at its discretion, combine a notice of Sanction with a notice of Overpayment.

(10)

Voluntary submission of an Individual Adjustment Request or overpayment amount after notice from the Authority does not prevent the Authority from issuing a notice of Sanction, but the Authority may take such voluntary payment into account in determining the Sanction.