Potential Medicare Advantage (MA) Plan Overpayments

Palmetto GBA has identified potential overpayments for claims processed prior to February 2018, related to Part A Jurisdiction J claims that were paid for Medicare beneficiaries covered under an MA Plan. Below, we have listed the limited scenarios that would warrant the claim being submitted to Fee For Service (FFS) Medicare.

• If a patient is enrolled in an MA Plan, the hospital or SNF would submit an inpatient claim with a condition code 04 or a teaching hospital would submit a condition code 04 and 69 in order to capture the benefit period. There would be no payment on the inpatient claim; however, if they were billing Indirect Medical Education (IME) FFS Medicare would pay the IME.
  • MA Plan covered period outpatient claims would never be billed to FFS Medicare.
• If the MA Plan beneficiary elects Hospice, then their claims are no longer the responsibility of the MA Plan. The patient has FFS Medicare for the time they are enrolled in Hospice. The hospital bills the hospice for all inpatient/outpatient terminal illness related services and bills FFS Medicare for all inpatient/outpatient service not related to Hospice with a condition code 07. FFS Medicare pays for the non-related services until the beneficiary revokes hospice; then the MA Plan picks up again.
• If the MA Plan beneficiary joins a qualifying clinical trial, FFS Medicare pays for the costs of routine services. Please refer to MLN Matters® Number: SE1344 (PDF, 73 KB)for proper billing instructions.
• If the beneficiary is in an inpatient stay and his enrollment in the MA plan takes after the stay begins, but prior to the discharge from that stay, FFS Medicare would pay for the inpatient stay.

For additional information, refer to the full list of exceptions to requirements (PDF, 522 KB) for MA plans to Cover FFS Benefits.

This article serves as our intent to provide notice that we plan to reopen Medicare’s initial determination of claims erroneously paid within four years of the date of this notice (May 7, 2018). The decision to reopen for good cause is in accordance with 42 CFR 405.986 and based on evidence that an obvious error was made at the time of the initial determination. Providers with claims subject to the above reopening will be contacted directly and provided with a claims listing of potential overpayments. If overpayments exist and result in financial hardship, you will be provided with several options for returning overpayments including negotiating an extended repayment plan. 

As required by 42 CFR 401.305 a provider/supplier who has received an overpayment must report and return the overpayment within 60 days after having identified the overpayment. (The overpayment can also be reported and returned by the date any corresponding cost report is due, if applicable). This requirement applies to overpayments identified within six years of the date the overpayment was received. In addition, when a government agency informs a provider/supplier of a potential overpayment, the provider/supplier has an obligation to accept the finding or make a reasonable inquiry to determine whether an overpayment exists and whether any similar overpayments exist within the six year lookback period.

Status:
6/12/2018: Providers with claims subject to the above reopening will receive a letter dated June 15, 2018 and provided with a claims listing of potential overpayments. If overpayments exist and result in financial hardship, you will be provided with several options for returning overpayments including negotiating an extended repayment plan.