Individual Overpayments Discovered Subsequent to the Fifth Year

80 – Individual Overpayments Discovered Subsequent to the Fifth Year (Rev. 294, Issued: 10-06-17, Effective: 07-03-17, Implementation: 07-03-17) There are special rules that apply when an overpayment is discovered subsequent to the fifth year following the year in which notice was sent that the amount was paid. Ordinarily, the provider or beneficiary will be considered without fault unless there is evidence to the contrary. In the absence of evidence to the contrary, the contractor will not demand and recover the determined overpayment. (One example of evidence to the contrary would be a pattern of billing errors. See Medicare Program Integrity Manual, Publication (PIM) 100-08, Chapter 3.) EXAMPLE 1: On May 9, 2016 Dr. A is notified that he has been paid $1005.00 for services provided to Mr. Smith, beneficiary. On January 6, 2022 the contractor determines that Dr. A was overpaid for the services to Mr. Smith, beneficiary. The contractor will not recover this overpayment as long as there is no evidence to the contrary because it was determined subsequent to the fifth year after notification of payment. (Any determination date on or after Jan. 1, 2022 will not be recovered.)(If evidence to the contrary existed, recoupment may be initiated. The PIM should be referenced and if necessary the appropriate Benefits Integrity unit at the contractor for guidance.) EXAMPLE 2: On May 9, 2016 Dr. A is notified that he has been paid $1005.00 for services provided to Mr. Smith, beneficiary. On September 20, 2019 the contractor determines that Dr. A was overpaid for the services to Mr. Smith, beneficiary. The contractor will attempt recovery of the overpayment. (Any determination dates up to and including Dec. 31, 2021 will be recovered.)