60 Days & 6 Years: The Numbers to Know to Comply With Medicare’s Overpayment Rule

Check that calendar!

You get a fairly clear picture of what this rule is about from its name: Medicare Reporting and Returning of Self-Identified Overpayments. If you discover Medicare gave you too much money, you have to give it back.

But there are some layers here, so let’s dig in for a refresher on some of the more important details. (It’s worth it when you consider the potential consequences of not complying include False Claims Act liability, monetary penalties, and exclusion from federal health care programs.)

60 Days Is All You Have to Give Medicare Money Back

Under the rule, providers and suppliers who get Medicare funds have to report and return overpayments by the later of these two:

  • 60 days after the date you identified the overpayment
  • The date a corresponding cost report is due (if applicable).

6 Years Is How Long Your Responsibilities Extend

The clock stops on this rule after six years, which isn’t so bad when you recall that the original plan was for a 10-year lookback period.

Experts warn that the lookback period extends back six years even if that time is before the rule became effective March 14, 2016.

Not Doing Audits Is a Bad Idea — Here’s Why

During the comment process, some worried this rule would create a chilling effect on audits if people sought to avoid finding overpayments. The final rule got around that by stretching the definition of “identification” to include the time when you actually discovered the issue or when you should have discovered it:

“A person has identified an overpayment when the person has or should have, through the exercise of reasonable diligence, determined that the person has received an overpayment and quantified the amount of the overpayment.”

In other words, plan regular audits and take action to ensure compliance because Medicare is going to hold you to that standard.

What Should You Watch for to Find Overpayments?

The final rule provides some examples to help give an idea of what it means to “identify” an overpayment under this rule. For instance, if you discover any of these, you need to get moving to ensure your claims and compensation comply with the rule:

  • Incorrect coding that yielded increased reimbursement
  • A patient death prior to the date of service on your claim
  • Services performed by an unlicensed or excluded provider
  • Internal audit results that indicate overpayment.

And remember that you’re responsible for overpayments you should have discovered, too, as in these examples:

  • A government agency performs an audit and alerts you to a potential overpayment that you need to investigate
  • You see a significant increase in Medicare revenue with no obvious cause.

How About You?

Have you had to look into the finer details of this rule? What tips would you give others?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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