Physician Practice

Look-back creates challenges for physician practices

Physician Practice Insider, April 5, 2016

Editor’s note: A final rule change issued last month by CMS could have a significant impact on how physician practices address billing and coding errors dating back six years. John Fanburg, managing partner and chair of the health law practice at Brach, Eichler in Roseland, NJ, spoke with HealthLeaders Media about the final rule and what physician practices should do to prepare for any billing discrepancies, and what the potential implications are for hospitals. The following is an edited transcript.

HLM: What does this rule change do?

Fanburg: The issue had to go with how far back the provider had to go to make the refund. For some time, there has been this 60-day time frame within which to make the refund due to the overpayment.

There has been some ambiguity as to when that clock runs and the proposed rule required the timeframe to go back 10 years. For obvious reasons, the healthcare industry totally rejected and lobbied against a 10-year look-back period, but they did settle on six.

Some providers would say that is not much better, but at least it’s not 10. The rule clarified the use of the word “identification.” When the overpayment is identified, what does that really mean, and what is the look-back period? These were critical for providers to understand how to be compliant.

HLM: What was the look-back period before the rule change?

Fanburg: There was always a proposed rule. No one was ever clear. There was a statute of limitations argument and depending upon the case it could be four, five, or six years.

HLM: When does the clock start on the 60-day identifier?

Fanburg: Where they ended up is when the provider knew or should have reasonably known. That could be played with as well. So, they impose an obligation to make reasonable inquiry if something were to happen. They are saying that if you get some type of credible inquiry or report you have an obligation relatively quickly based upon the facts to make due inquiry in terms of whether or not there was a problem.

This article was originally published on HealthLeaders Media.

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