I recently offered training to a health system about how to respond to whistleblower complaints. Regular readers will know many of the tips I discussed.
Hopefully, you know why a Medicare refund should only go back 48 months, not six years, unless there is fraud or similar fault that necessitates the longer lookback.
We have covered the fact that Local Coverage Determinations (LCDs) are not binding, and that unless a National Coverage Determination (NCD) specifically says services are not covered, it only extends, rather than limits, coverage. In other words, you should almost never be refunding off of LCDs or NCDs.
But it’s been a long time since I’ve written about when you should make a refund. And that decision can have a significant economic impact on you. There are many lawyers who recommend using the U.S. Department of Health and Human Services (HHS) Office of Inspector General’s (OIG’s) self-disclosure protocol, or going to the local U.S. Attorney’s Office when you want to make a refund.
While I have done each, I believe they should be done exceedingly rarely. I bet 99 percent of the refunds I have been involved with are made directly to the Medicare Administrative Contractor (MAC). (To be clear, I almost never send a refund under my name. When I am involved, I am ghostwriting a letter to be sent under the compliance professional’s signature.)
There is a very simple reason for this. If you make a refund to a U.S. Attorney, or via the OIG’s self-disclosure protocol, they are going to expect you to pay 50 percent more than the amount of the actual overpayment. If the overpayment was $100,000, they will expect $150,000. In exchange for this additional payment, you will get a release under the False Claims Act (FCA).
That release does have some value; you can be confident that you will not have to face a qui tam lawsuit, because the claims will have been released. But that additional 50 percent is nothing to sneeze at.
It is an expensive sneeze, and I question the value you get for paying that extra sum. While a release assures you that you will not have to face an FCA case, the practical reality is that it is difficult for someone to bring a credible False Claims Act case after you have made a refund.
It’s possible, but they have an uphill climb. And if they do bring such a case, the odds are pretty good you’ll be able to resolve it for that additional 50-percent payment if the government concludes that your disclosure was made in good faith. You might ultimately pay a bit more than the 50 percent, but you have excellent odds of winding up in essentially the same place you would have been at if you had gone to the U.S. Attorney or the self-disclosure protocol.
That extra 50 percent you pay is akin to an insurance premium. It doesn’t seem worth it to spend nearly as much on an insurance premium as you would hope to get in the ultimate payout, especially given that you often won’t be getting any payout at all. If you are making multiple refunds, you will certainly pay more if you routinely pay 50 percent, rather than taking your chances.
It makes far more sense to refund the overpayment to the MAC and see what happens.
That is why, unless I think one of our employees did something intentionally wrong, I am going to cut a check for the overpayment amount to the MAC and leave the OIG and U.S. Attorney’s office out of it.
EDITOR’S NOTE:
The opinions expressed in this article are solely those of the author and do not necessarily represent the views or opinions of MedLearn Media. We provide a platform for diverse perspectives, but the content and opinions expressed herein are the author’s own. MedLearn Media does not endorse or guarantee the accuracy of the information presented. Readers are encouraged to critically evaluate the content and conduct their own research. Any actions taken based on this article are at the reader’s own discretion.
The U.S. Court of Appeals for the Sixth Circuit has handed the False Claims Act (FCA) bar another lesson in humility – and perhaps prompted
We all know now that the federal telehealth waivers were allowed to expire while Congress continues the stalemate over the budget. And in the Centers
Please log in to your account to comment on this article.
Denials continue to delay reimbursement, increase administrative burden, and threaten financial stability across healthcare organizations. This essential webcast tackles the root causes—rising payer scrutiny, fragmented workflows, inconsistent documentation, and underused analytics—and offers proven, data-driven strategies to prevent and overturn denials. Attendees will gain practical tools to strengthen documentation and coding accuracy, engage clinicians effectively, and leverage predictive analytics and AI to identify risks before they impact revenue. Through real-world case examples and actionable guidance, this session empowers coding, CDI, and revenue cycle professionals to shift from reactive appeals to proactive denial prevention and revenue protection.
Sepsis remains one of the most frequently denied and contested diagnoses, creating costly revenue loss and compliance risks. In this webcast, Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, provides practical, real-world strategies to align documentation with coding guidelines, reconcile Sepsis-2 and Sepsis-3 definitions, and apply compliant queries. You’ll learn how to identify and address documentation gaps, strengthen provider engagement, and defend diagnoses against payer scrutiny—equipping you to protect reimbursement, improve SOI/ROM capture, and reduce audit vulnerability in this high-risk area.
Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY26 IPPS, including new ICD-10-CM/PCS codes, CCs/MCCs, and MS-DRGs, plus insights, analysis and answers to your questions from two of the country’s most respected subject matter experts.
This third session in our 2026 IPPS Masterclass will feature a review of FY26 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.
Federal auditors are zeroing in on Inpatient Rehabilitation Facility (IRF) and hospital rehab unit services, with OIG and CERT audits leading to millions in penalties—often due to documentation and administrative errors, not quality of care. Join compliance expert Michael Calahan, PA, MBA, to learn the five clinical “pillars” of IRF-PPS admissions, key documentation requirements, and real-life case lessons to help protect your revenue.
During this essential RACmonitor webcast Michael Calahan, PA, MBA Certified Compliance Officer, will clarify the rules, dispel common misconceptions, and equip you with practical strategies to code, document, and bill high-risk split/shared, incident-to & critical care E/M services with confidence. Don’t let audit risks or revenue losses catch your organization off guard — learn exactly what federal auditors are looking for and how to ensure your documentation and reporting stand up to scrutiny.
Learn how to navigate the proposed elimination of the Inpatient-Only list. Gain strategies to assess admission status, avoid denials, protect compliance, and address impacts across Medicare and non-Medicare payors. Essential insights for hospitals.
RACmonitor is proud to welcome back Dr. Ronald Hirsch, one of his most requested webcasts. In this highly anticipated session, Dr. Hirsch will break down the complex Two Midnight Rule Medicare regulations, translating them into clear, actionable guidance. He’ll walk you through the basics of the rule, offer expert interpretation, and apply the rule to real-world clinical scenarios—so you leave with greater clarity, confidence, and the tools to ensure compliance.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
