Protocol for voluntary self-disclosure of provider overpayments

Protocol for voluntary self-disclosure of provider overpayments

The Indiana Family and Social Services Administration (FSSA) has established a self-disclosure protocol for providers wishing to report Medicaid and Children's Health Insurance Program (CHIP) fee-for-service overpayments they have identified.

The FSSA understands that internal compliance processes often identify improper payments that have been made to a provider. While providers that determine they have received inappropriate payments from the Indiana Health Coverage Programs (IHCP) are obligated by federal and state law to return the overpayments, the FSSA believes a process to facilitate reporting and repayment of these improper payments is beneficial to providers and the State. The self-disclosure protocol gives providers an easier process for reporting matters that involve possible fraud, waste, abuse, or inappropriate payment of funds, whether intentional or unintentional, to the FSSA. By enhancing the State's relationship with providers through this self-disclosure approach, the FSSA hopes to further its efforts to eliminate fraud, waste, and abuse, while also offering providers an opportunity to reduce their legal and financial exposure.

Providers should utilize the self-disclosure protocol to report the following self-identified items:

  • Provider billing system errors or issues that result in overpayments
  • Potential violations of federal, state, or local laws
  • Potential violations of regulations
  • Potential violations of billing, coding, or other healthcare policies

Note that the preceding list is not an all-inclusive list of potential errors or issues that may be reported. However, errors or overpayments that are the result of issues with the IHCP claim-payment processing system should not be reported through this self-disclosure mechanism. Please report IHCP claim-processing payment issues to the IHCP Provider and Member Concerns Line at (800) 457-4515, Option 8 for Audit Services.

Please note that the FSSA requests that the self-disclosure protocol be utilized in the following scenarios:

  • To self-report overpayments involving specific compliance issues
  • To self-report overpayments involving cumulative amounts greater than $1,000
  • To self-report overpayments involving fraud or violations of law

Simple, more routine occurrences of overpayments that do not meet the previously listed criteria should continue through typical methods of resolution, which may include voiding or adjusting the claims UNLESS the provider feels compelled to self-report the overpayments through this process.

Potential Benefits of Self-Disclosure

While the resolution of each self-disclosure depends upon the merits of the specific situation, the FSSA reminds providers that self-disclosure of an overpayment will, in many circumstances, result in a better outcome for the provider than if the FSSA or other review organization discovers the matter independently.

Managed Care Overpayment Self-Disclosures

The self-disclosure process outlined on this web page is designed for providers that wish to report Medicaid and CHIP fee-for-service overpayments. Please do not report HIP, Hoosier Healthwise, or Hoosier Care Connect overpayment issues using this process. Should you need to report managed care overpayments, please contact the IHCP Provider and Member Concerns Line at (800) 457-4515, Option 8 for Audit Services.

Self-Disclosures Involving Claim Sampling or Pharmacy Claims

The self-disclosure process outlined in this document is designed for providers who wish to report claim-specific Medicaid and CHIP fee-for-service overpayments that do not include claims for pharmacy services billed on the Pharmacy Claim Form. If you would like to pursue a sampling approach or disclose overpayments related to pharmacy claims, you may use the Self-Disclosure Form to request consultation with a Program Integrity representative. Include information and your request for consultation in Section 5 of the form. If you wish to discuss claim sampling or pharmacy overpayment issues with a Program Integrity representative, please do not include any dollar estimates or claims in your submission.

Provider Responsibilities

Please be advised that under federal law, a provider who identifies an overpayment must report the overpayment and return the entire amount to a Medicaid program within sixty (60) days after it is identified. 42 U.S.C. § 1320a-7k(d). A provider who retains an overpayment after the sixty (60) day deadline incurs an obligation under the federal False Claims Act and may be subject to criminal and civil liability, including civil monetary penalties, treble damages and, potentially, exclusion from participation in federal health care programs. Id. A provider who fails to make the repayment within sixty (60) calendar days of identification may also be at risk from a "whistleblower" lawsuit. The FSSA will accept repayments made within sixty (60) calendar days of your identification of an overpayment or your receipt of this notice of an overpayment.

Under the Patient Protection and Affordable Care Act (PPACA), a provider who identifies an overpayment outside of routine adjustments "shall-(A) report and return the overpayment to the Secretary, the State, an intermediary, a carrier, or a contractor, as appropriate, at the correct address; and (B) notify the Secretary, State, intermediary, carrier, or contractor to whom the overpayment was returned in writing of the reason for the overpayment." PPACA 6402(d)(1)(A) & (B). In Indiana, one original and one copy of the completed Voluntary Self-Disclosure of Provider Overpayments Packet, including the following information must be submitted when an overpayment is self-identified:

  • Completed Self-Disclosure Form (Part II)
  • Completed Payment Options (Section 6 of the Self-Disclosure Form), identifying whether the overpayment will be satisfied by a refund check or a withhold from future payments
  • Completed Provider Corrective Action Plan (Part III)
  • Completed Overpaid Claims Detail (Part IV)
  • Completed IHCP Request to Waive Appeal Rights (Part V)

An electronic form is available in PDF format at the end of this document for providers to download, complete, and mail to the following addresses.

The correct address to which a provider should submit the original version of the packet, and repayment if by check, is:

IHCP Program Integrity
ATTN: SUR Audit and Overpayment
P.O. Box 636297
Cincinnati, OH 45263-6297

The correct address to which a provider should submit a copy of the packet is:

Family & Social Services Administration
Office of Medicaid Policy and Planning
Attn: Surveillance and Utilization Review Audit Manager
402 W. Washington Street, Room E442, MS58
Indianapolis, IN 46204

NOTE: A copy of the repayment check must be submitted to the second address.

Failure to complete the Voluntary Self-Disclosure of Provider Overpayments Packet, including associated attachments, and to provide a refund or a plan to refund said overpayment qualifies as failure to comply with PPACA. In addition, a provider that fails to do so may be subject to further action by the FSSA including, but not limited to, an audit of the provider's records and/or referral for further investigation. The provider may also be liable for violations of the Federal False Claims Act.

It is each provider's responsibility to maintain detailed records of any overpayment identified and returned in order to demonstrate compliance (regardless of refund method).

After the FSSA reviews all disclosure submission material, you will receive a letter indicating the final overpayment dollar amount and the procedure for remitting additional payment, if necessary. If the submitted claim data does not materially match the IHCP payment data, or if the FSSA does not accept your self-disclosure results, you will receive correspondence with further instructions. Self-disclosure assumes that the provider has waived the right to administrative review and appeal. Consequently, you are asked to complete and submit the IHCP Request to Waive Appeal Rights (Part V) when you submit your self-disclosure form and data.

Please note that the previous list of requested information may not be all-inclusive, as other information may be required, depending upon the circumstances of your self-disclosure. Files containing claims information and all self-disclosure correspondence from all previous sections are to be submitted in an electronic Health Insurance Portability and Accountability Act (HIPAA)-compliant[1] format (via encrypted CD, DVD, or other similar format) to the addresses previous listed.

Should you have any questions concerning the requested information, please contact the IHCP and Member Concerns Line at (800) 457-4515, Option 8 for Audit Services.

Our Responsibilities

The FSSA is required to identify and recover overpayments as mandated by federal and state laws and regulations. Title XIX of the Social Security Act, Sections 1902 and 1903, and regulations found at 42 CFR 456, stipulate that utilization review activities of the FSSA ensure that services rendered are necessary and in the optimum quality and quantity. These federal regulations also require the FSSA to have the ability to identify and refer cases of suspected fraud and/or abuse in the IHCP for investigation and/or prosecution. Utilization review activities safeguard against unnecessary care and services, and ensure that payments are appropriate, according to the coverage policies established by the IHCP (Indiana Administrative Code [IAC] 405 IAC 5-1). The results and recommendations of reviews conducted for this purpose are specifically designed to assist providers in achieving compliance, as well as avoiding future financial penalties incurred when payment for services is recouped.

Therefore, please be advised that self-disclosure of overpayments alone does not absolve a provider of additional liability that may be associated with claims included within a review period or claims included within a time period not examined during an internal review. Please also note that the FSSA's acceptance of your review results and any overpayment associated therewith does not waive the right to further audit or to conduct an examination of these claims, or any other claims within the time period covered by your internal review process. These claims continue to be subject to review by the FSSA, the Centers for Medicare & Medicaid Services (CMS), the Office of Inspector General (OIG), other State or federal agencies, or other investigative entities.

Click here to access the Voluntary Self-Disclosure of Provider Overpayments Packet

[1] Documentation/information must be submitted in a Health Insurance Portability and Accountability Act (HIPAA)-compliant and secure manner. Please do not email or mail documents without using appropriate encryption methods. Passwords to encrypted files must be emailed separately from the documentation or data, or provided via telephone.