Current Status

02/20/2020: Providers that received the Phase III Settlement Offer letters are reminded that, if they wish to accept CMS’s settlement offer, they must sign, date, and return their settlement letters, along with payment by check for the full settlement amount, to Palmetto GBA by March 3, 2020.

Providers are requested to return their signed settlement letters and checks to the address indicated in the settlement letter. Checks should be made payable to “Medicare.” 

Providers that elect not to accept CMS’s settlement offer will receive a demand letter for the full overpayment amount. These providers will have appeal rights for the claims involved. CMS estimates that these demand letters will be issued on or about March 20, 2020.

See the CPIL postings dated February 5, 2020, and December 20, 2019, for additional information.

Providers that have any questions about CMS’s settlement offer letters or that have misplaced their letters, should immediately contact Palmetto GBA at MA.Response@palmettogba.com.

Situation Identified May 7, 2018
The original
article entitled, Potential Medicare Advantage (MA) Plan Overpayment was published on May 7, 2018, and updated on June 12, 2018.

Previous Status:

02/05/2020: Providers that received the Phase III Settlement Offer letters in early January 2020 are reminded that, if they wish to accept CMS’s settlement offer, they must sign, date, and return their settlement letters, along with payment by check for the full amount requested, to Palmetto GBA by not later than March 3, 2020. Checks should be made out to “Medicare.”

As indicated in the settlement letters, return the signed settlement letters and checks to the following address. Be sure to apply adequate postage.

Palmetto GBA, LLC.
P.O. Box 100312
Columbia, S.C.   29202–3312

Providers that have any questions about CMS’s settlement offer letters and/or that have misplaced their letters should immediately contact Palmetto GBA at the following email address: MA.Response@palmettogba.com. Providers may also contact the Provider Contact Center (877–567–7271) for more information. Providers wishing to accept the CMS settlement offer are encouraged to not wait until the last minute to send in their settlement agreements.

01/03/2020: The Phase III Settlement Offer Letters were mailed to affected providers earlier today (January 3, 2020). These CMS settlement offers are intended to address all remaining unresolved “MA overpayment” claims. Providers have sixty days (until March 3, 2020) to accept CMS’s settlement offer. See the 12/20/2019 CPIL update for additional details.

As was the case for the earlier Phase I and Phase II letters, these third (Phase III) letters are directed to the attention of each provider’s Chief Executive Officer (stamped in red letters on the envelope). Providers need to be alert for these letters, given their time-sensitivity. Only providers affected by Phase III of CMS’s approach to resolving the MA overpayments will receive these letters.

12/20/2019: The Third and final letter — which will be a Settlement Offer on CMS letterhead — will be mailed to affected providers on January 3, 2020. This CMS letter will contain a settlement offer covering all remaining unresolved “MA overpayment” claims. Key points are:

  • Provider will receive the Third Letter for unresolved MA overpayment claims where the MAO opted against making a voluntary payment or arranging for rebilling of claims
  • The Third Letter will contain a CMS settlement for the unresolved MA overpayment claims and will contain a listing of the specific claims included in CMS’s settlement offer
  • Providers receiving a CMS settlement offer will have sixty (60) days to respond
  • Providers that accept the CMS settlement offer will retain a sizable portion (60%) of the original payments but will need to repay the balance specified in the settlement offer
  • Providers that do not accept the CMS settlement offer will receive a Medicare demand letter for the full balance, which they will need to repay; however, these providers will be permitted to pursue appeals on any of the claims if they wish to

As was the case for the First (Phase I) letters, issued in late November 2019, and the Second (Phase II) letters, issued in early December 2019, these Third (Phase III) letters will be directed to the attention of each provider’s Chief Executive Officer (stamped in capital red letters on the envelope).  Providers need to be alert for these letters, given their time-sensitivity.  Only providers affected by Phase III of CMS’s approach to resolving the MA overpayments will receive these letters.

12/6/2019: As advised on the November 27, 2019, status update, the Timely Filing Waiver (TFW) Demand Letters will be issued to affected providers. In addition to identifying FFS claims requiring repayment, these letters will identify participating MA plans and their designated Point of Contact (POC). The 1,066 demand letters were mailed on December 6, 2019.

11/27/2019: As advised in the November 8, 2019, status update, some time ago CMS requested that the affected Medicare Advantage (MA) Plans not making voluntary direct payments to the Medicare FFS program give consideration to waiving their claims filing deadlines. This will enable providers to rebill their claims. In response, more than 100 MA Plans agreed to give consideration to these aged claims for payment.

In the November 8 status update, providers were also advised that during Phase II, a second MA letter would be mailed in early December.

On December 6, 2019, the Timely Filing Waiver (TFW) Demand Letters will be issued to affected providers. In addition to identifying FFS claims requiring repayment, these letters will identify participating MA plans and their designated Point of Contact (POC). Each TFW letter will include the following:

  • Certain information applicable to the provider’s specific circumstance(s); for instance, whether or not the provider may receive a Phase III letter
  • A claims listing that clearly delineates the MA overpayment claims that are encompassed by the letter’s demand for repayment
  • An MA plan listing (and their designated POCs) that corresponds to the provider’s FFS overpayment(s)

Since not all MA overpayments are included in the TFW process, each provider should carefully review its claims listing (attached to its letter) to identify which of its erroneous MA overpayments need to be (1) repaid to Medicare Fee For Service (FFS), and (2) pursued through the MA plans’ POC.

Additional information is available in articles entitled, “Phase II Timely Filing Waiver (TFW) Demand Letters,” “Medicare Advantage (MA) Plan Overpayments: Update” and “Medicare Advantage (MA) Plan Overpayments - Frequently Asked Questions (FAQs)”. Questions may be addressed to MA.Response@palmettogba.com.

11/21/2019: As advised on the November 8, 2019, status update, Palmetto GBA and Centers for Medicaid & Medicare Services (CMS) will initiate resolution of the Medicare Advantage (MA) Plan Overpayments in the upcoming weeks. 

The first letters will be mailed on Thursday, November 21, 2019, with the majority being mailed on Friday, November 22, 2019. This letter will advise providers as to which of their claims were fully resolved by these voluntary MAO payments. These letters will be purely informational; there is no overpayment for the claims included in them, and providers will not have to take any follow-up actions on the claims referenced in this first letter.

As a reminder, these letters will be mailed in envelopes from Medicare with “ATTN: Chief Executive Officer” stamped in RED underneath the provider’s business address.

11/8/2019: Palmetto GBA and Centers for Medicaid & Medicare Services (CMS) will initiate resolution of the Medicare Advantage (MA) Plan Overpayments in the upcoming weeks. Those providers involved in the MA Plan Overpayments will receive, depending on their specific situations and claims, either one, two, or three letters addressed to the provider’s physical address (as listed on the 855A Enrollment form). Providers may need to make decisions based on these letters. Providers should watch for these letters, which will be directed to the attention of the Chief Executive Officer (CEO), stamped in red.

First Letter, Late November: CMS made the companies that sponsor MA plans (these companies are called MA organizations, or MAOs) aware of the Jurisdiction J overpayments situation. Several dozen MAOs, which collectively sponsor 195 MA plans, on a purely voluntary basis agreed to make repayments to the Medicare FFS program, in order to mitigate financial and administrative burden for providers. These voluntary MAO payments totaled $26 million, resolved 133,000 erroneous claims and benefited nearly 2,000 providers. The first letters, to be issued on/about November 22, will advise providers as to which of their claims were fully resolved by these voluntary MAO payments. These letters will be purely informational; there is no overpayment for the claims included in them, and providers will not have to take any follow-up actions on the claims referenced in this first letter.

Second Letter, Early December: Three dozen MAOs, which collectively sponsor about 108 MA plans, agreed to allow providers to re-bill their claims or otherwise pursue payment, even though their respective claims filing deadlines had passed. While providers who filed these claims to Medicare FFS will be required to repay the Medicare FFS program, these providers will have the option to re-bill their claims and have them considered for payment by the MAOs. The second letters, to be issued on/about December 6, will request repayment to the Medicare FFS program, but these letters will also furnish information to the providers on how to contact the MAOs involved. For each MAO agreeing to waive its claims filing deadline, providers will receive point of contact information to pursue payment. Providers will need to take follow-up action on these letters, namely, they will need to repay Medicare FFS and to contact the MAO points of contact if they wish to pursue re-billing.

Third Letter, Early January: In many other cases, the MAO elected to not make a voluntary repayment or arrange for rebilling of claims. This situation leaves about $12 million of the overall MA Plan Overpayments unresolved. The third letters will contain a CMS offer to make settlement for the unresolved claims and will contain a listing of the specific claims included in CMS’s settlement offer. The settlement offer letters will be issued on/about January 3, 2020. Providers receiving these CMS settlement offers will have sixty (60) days to respond. Providers that accept the CMS settlement offer will retain a sizable portion of the original payments; but will need to repay the balance specified in the settlement offer. Providers that do not accept the CMS settlement offer will receive a Medicare demand letter for the full balance, which they will need to repay; however, these providers will be permitted to pursue appeals on any of the claims if they wish to.

As noted above, depending on their circumstances, some providers involved in the MA Plan Overpayments may receive all three of these letters, but some affected providers may receive only one or two of the letters. Providers need to be alert to these letters, which will be marked as described above, and providers need to carefully review the listing of claims and other information that is included with each specific letter.

Conclusion
Palmetto GBA’s review of “exception cases” resolved one set of the MA Plan Overpayments. Some providers proactively initiated the cancellation of erroneously paid claims, resolving another set of the MA Plan Overpayments. Voluntary payments by certain MAOs have resolved many of the erroneous FFS payments. Between late November and early January, providers will be receiving one, two, or three letters; each letter will lay out the resolution approach specific to a specific set of claims within the overall MA Plan Overpayments. Providers need to be alert to these letters. While the November letter will be purely informational, the December and January letters will require provider follow-up.

Additional information is available in articles entitled, “Medicare Advantage (MA) Plan Overpayments: Update” and “Medicare Advantage (MA) Plan Overpayments - Frequently Asked Questions (FAQs)”. Questions may be addressed to MA.Response@palmettogba.com

2/19/2019: Information concerning the status of the Medicare Advantage (MA) Overpayments for outpatient claims will be shared in a few weeks (we anticipate in late March or April).

On a separate but related topic, a small number of providers (52) received letters dated January 28, 2019, notifying the providers of MA overpayments associated with a small number of inpatient claims (fewer than 100 claims altogether are affected). The letters gave notification of Medicare’s intention to reopen these inpatient claims within the allowable four-year window to reopen. Palmetto GBA has heard from some providers that some of these inpatient claims related to hospice services. If these inpatient claims were submitted without condition code 07, we are unable to identify if the claim related to hospice services. If a provider received the January 28 letter, and it believes the claim related to hospice services, the provider should first verify whether it submitted the claim with condition code 07. If the provider inadvertently left condition code 07 off the claim, the provider should contact Palmetto GBA to reopen the claim, and timely filing will be waived for those exceptions. The January 28 letter lays out other potentially valid exceptions and advised affected providers how to submit their exception requests to Palmetto GBA. Providers are being given until February 27, 2019, to submit their exception requests to Palmetto GBA, in advance of Medicare’s reopening of these inpatient claims.

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