Medicare Advantage (MA) Plan Overpayments: Background

The intent of this article is to notify the provider community of CMS’s and Palmetto GBA’s final plan for resolving certain erroneous Medicare Fee-For-Service (FFS) program payments.

Palmetto GBA previously issued two notifications (the first dated June 15, 2018, for outpatient claims; the second dated January 28, 2019, for inpatient claims) that certain claims were paid incorrectly by the Medicare Fee-For-Service (FFS) program for Medicare beneficiaries enrolled in MA plans between July 2014 and January 2018. The applicable MA plans should have paid these claims for their enrollees, rather than the Medicare FFS program.

A thorough investigation was conducted to not only ensure protection of Medicare trust fund but to evaluate the concerns of the stakeholders. This allowed the Centers for Medicare & Medicaid Services (CMS) the opportunity to consider multiple aspects of this issue, and to give Palmetto GBA time to research “exception cases” submitted by providers. Palmetto GBA has completed its review of all “exception cases.” Some “exception cases” were resolved in favor of the provider while others were not. The submitting providers have been notified of Palmetto GBA’s findings.

In line with CMS Administrator initiatives, CMS and Palmetto GBA will resolve the remaining MA Plan Overpayments in three resolution phases:

• PHASE ONE: Close-Out Letters (PDF, 116 KB), Issuance in Late November 2019. Nearly 2,000 providers will receive notification letters that will reduce any burden of MA overpayments for JJ providers. After CMS contacted them, several dozen MA organizations (MAOs) representing nearly 200 MA plans have made voluntary payments to Medicare FFS, redeeming $26 million of the potential MA overpayments. The letters will include a listing of claims and will show the Plan ID and Plan Name whose voluntary payment redeemed the potential overpayments. Providers should retain this letter for their records; no other action or response is required to these letters.

A list of MA plans (XLSX, 17 KB), whose sponsoring MAOs made voluntary direct payments to Medicare FFS, is available. These voluntary MAO payments resolved many of the potential MA overpayments

• PHASE TWO: Waived Claims Filing Deadline Letters, Issuance in Early December 2019. Certain providers will receive letters that will require repayment of the specified MA Plan overpayments. However, these letters will also identify the MA plans which have agreed to waive their claims filing deadlines, and to give consideration to claims involving their enrollees. These letters will provide a specific point of contact for each MA plan. This individual can assist providers wishing to rebill their claims and/or to otherwise resolve their billings. Altogether, this phase involves approximately three dozen MAOs that represent 108 MA plans. Altogether, CMS will require repayment of about $2.7 million in FFS payments in this phase, a small portion of the original MA Plan Overpayments issue. All of these demand letters will afford and specify providers’ administrative appeal rights in keeping with FFS rules.
• PHASE THREE: Settlement Offers, Issuance in Early January 2020. CMS will make settlement offers to providers to resolve the remaining MA overpayments that are not resolved under the first two phases of activity described above. Settlement offers will identify the total potential MA overpayment, and will provide for 40 percent of the total to be repaid to Medicare and 60 percent of the total to be retained by providers. Providers will have up to sixty (60) days to accept the settlement offers. Providers that do not accept the settlement offers will receive a demand letter for the total potential MA overpayment amount. These demand letters will afford and specify providers’ administrative appeal rights in keeping with FFS rules.

PALMETTO GBA ADVISES ALL PROVIDERS TO LOOK FOR ENVELOPES FROM MEDICARE WITH “ATTN: CHIEF EXECUTIVE OFFICER” STAMPED IN RED UNDERNEATH THE PROVIDER’S BUSINESS ADDRESS.

“Medicare Advantage Overpayments” in A/B MAC Jurisdiction J
General Acute Hospitals in Alabama, Georgia and Tennessee
Breakdown by Resolution Approach

Note: The following chart includes general acute hospitals only. The chart does not include VA hospitals, children’s hospitals, critical access hospitals, psychiatric hospitals, rehab and long-stay hospitals, and specialty hospitals. Claim volumes are rounded to nearest 100 and dollar values are rounded to nearest $100,000. Rounding may cause minor discrepancies between totals and sub-elements.

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^I This column excludes MA overpayments that have already been self-cancelled by the provider and situations where Palmetto GBA found that a “valid exception” existed (e.g., prior refunds made, etc.).

ⁱⁱ The data in this column represents the maximum number of providers to receive demand letters for claims to be resolved through the MAO Timely Filing Waiver process. Demand letters will include appeal rights.

ⁱⁱⁱ This column represents the maximum number of providers receiving CMS Settlement Offer letters for unresolved claims. Providers rejecting the CMS Settlement Offer will receive a subsequent demand letter (with appeal rights).

Resources
Please view the Frequently Asked Questions article to view common MA Plan Overpayments questions.

Additional information is available in the Phase II Timely Filing Waiver (TFW) Demand Letters article.

If you have any questions not addressed in the web postings, FAQs or CPIL updates, please contact our office at MA.Response@palmettogba.com.