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Compliance Update: Point the Right Finger When Dealing With Overpayments

Know your own books before chatting with the OIG

No one wants to get burned by an auditor for receiving overpayments for claims, but just because you get more money than you charged for one claim doesn't mean you need to rush to report it. Some circumstances call for further self-evaluation before inviting outside eyes into your accounting books, so find out when - and how - to kiss and tell.

Don't Jump the Gun
When you discover an error that you think may be an overpayment, don't decide your course of action right away, says Wayne Miller, Esq., founding partner of Compliance Law Group in Los Angeles. "At that point, you need to be more deliberate and figure out exactly what happened. Do your own investigation so you can present what happened in the best and most accurate way," he says.
For example, suppose you work in a facility where an employee comes to you and says that a certain person asked her to add something to the chart that didn't occur. Now, such an allegation may indeed mean that the person asked her to supplement the report with incorrect information to buttress aggressive claims. But that doesn't mean you should automatically call Medicare or the HHS Office of Inspector (OIG) and inform the agency that you have a documentation problem. Instead, step back and find out the exact nature of the allegation, and determine whether the employee's claims are legitimate. They could be due to a misunderstanding or a small mistake.
Develop an Airtight Policy in Advance
"If you've got a compliance plan in place that includes reference to these kinds of issues - and specifically outlines what decision-making process you go through when dealing with these tough issues - that is very important," Miller says. Because if anyone should challenge you later about the decision you made, they'll want to know you followed policy consistently. The government reviewer or payer may be more impressed by the fact that your compliance program led you to find the problem, examine it, and determine how to handle it.
"You need to establish procedures to follow," Miller says, in which you have concrete methods to answer questions such as "In what cases will we repay these dollars? In what cases are we going to investigate further? Can we clearly identify obvious reasons for
the errors?"
Can You Keep a Secret?
Let's say you've analyzed a payment error and discovered that the overpayment was due to a minor mathematical mistake. If the amount is small, many facilities choose to keep these items as line items, because they don't consider the amount of money involved [...]

- Published on 2003-11-06