Notice to Providers:
Information contained in this protocol has been updated as of August 2022. Notable changes include:
- Claims must be verified before submitting payment.
- Clarification made regarding Provider Group submissions – only ONE National Provider Identifier should be submitted per disclosure.
- Secure File Transfer Protocol can be used for submitting protected health information securely.
Resources
The Indiana Health Coverage Programs has established a self-disclosure protocol for providers that need to report Medicaid and Children's Health Insurance Program fee-for-service overpayments they have identified. The IHCP 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 Code of Federal Regulations 42 CFR 456, stipulate that utilization review activities of the IHCP ensure that services rendered are necessary and in the optimum quality and quantity. Federal regulations found under 42 CFR 455 also require the IHCP to have the ability to identify and refer cases of suspected fraud and/or abuse in the IHCP for investigation and/or prosecution.
The IHCP understands that internal compliance processes often identify improper payments that have been made to a provider. Providers that have discovered an inappropriate payment from the IHCP are obligated by federal and state law to return the overpayments. The state of Indiana is required by federal law (42 CFR 433) to repay the federal share of the overpayment. The IHCP 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 IHCP. By enhancing the state's relationship with providers through this self-disclosure approach, the IHCP hopes to further its efforts to eliminate fraud, waste and abuse, while also offering providers an opportunity to reduce their legal and financial exposure.
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 IHCP's acceptance of the provider's 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 the provider's internal review process. These claims continue to be subject to review by the IHCP, the Centers for Medicare & Medicaid Services, the Office of Inspector General, other state or federal agencies, or other investigative entities.
Failure to complete and submit the Voluntary Self-Disclosure of Provider Overpayments Form, including associated attachments, and to provide a refund or a plan to refund said overpayment qualifies as failure to comply with the Patient Protection and Affordable Care Act. In addition, a provider that fails to do so may be subject to further action by the IHCP 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.
Please do not report managed care overpayment issues using this process. If providers need to report managed care overpayments, contact the specific managed care entity (MCE) involved or contact the IHCP Provider and Member Concerns Line at 800-457-4515, option 8 for Audit Services.
Note: ANY self-disclosures received for MCE claims reported to the FSSA will be returned.
Providers should use the self-disclosure process to report the following, but not limited to, 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
- Overpayments involving specific compliance issues
- Overpayments involving cumulative amounts greater than $1,000
- Overpayments involving fraud or violations of law
In the event a provider identifies a single claim, or a small number of claims, as erroneous, the IHCP recommends the provider void and (if applicable) resubmit the claim correctly through the IHCP claim-processing system.
Errors or overpayments that are the result of issues with the IHCP claim-processing system should NOT be reported through this self-disclosure mechanism.
Instead, please report such issues to 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 on this page is designed for providers that wish to report claim-specific Medicaid and CHIP fee-for-service overpayments, excluding pharmacy claims. If a provider chooses to use a sampling approach to determine an overpayment amount for a large number of claims, an explanation of the extrapolation process used and how the overpayments were discovered must be included in Section 5 of the Voluntary Self-Disclosure of Provider Overpayments Form.
If you wish to discuss claim sampling methodology or pharmacy overpayment issues with a Program Integrity representative, please submit the request via email to ProgramIntegrity.FSSA@fssa.in.gov.
Provider Responsibilities
- Note: Please note that a change in the process has occurred and providers are asked to refrain from making payments with the initial self-disclosure until claims are verified and the Final Calculation of Payment has been sent.
Please be advised that under federal law, 42 U.S.C. § 1320a-7k(d), a provider that identifies an overpayment shall report the overpayment and return the entire amount to a Medicaid program within 60 days after the overpayment is identified. Further, a provider that retains an overpayment after the 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 healthcare programs. A provider that fails to report a suspected overpayment and make the repayment within 60 calendar days of receipt of the final notification of overpayment may also be at risk from a "whistleblower" lawsuit. When a suspected overpayment is reported, the IHCP will accept repayments made within 60 calendar days of the provider's receipt of the final notification of overpayment.
Under Section 6402(d)(1) of the PPACA, a provider that 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."
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). Please note that if providers undertake an audit or review of their Medicare claim population, providers cannot use the Medicare error rate on their Indiana Medicaid claim population. If a provider chooses to use statistically valid random sampling and extrapolation to determine an overpayment amount for a large number of claims, providers should submit an explanation of the extrapolation process used and how the overpayments were discovered.
To avoid overpayments being included in subsequent Program Integrity audits, providers should adjust their claims (if before timely filing) or request claim adjustments as soon as overpayments are identified by internal audit procedures.
Provider Group Self-Disclosures
Only one National Provider Identifier (NPI) should be submitted per self-disclosure for a provider group. Without the NPI, the self-disclosure is incomplete and will be rejected and returned to the provider.
Submitting Self-Disclosure Form and Supporting Documentation
Providers must submit the self-disclosure form and supporting documentation either electronically through Secure File Transfer Protocol (SFTP) or by mail. No repayments should be made at the time of the initial self-disclosure. Providers need to receive verification of the overpayment amount from IHCP Program Integrity before they submit any repayments.
Submitting Self-Disclosure by SFTP
The provider can submit a copy of the form electronically via SFTP. To get set up with SFTP, complete the Indiana FADS Secure File Transfer Form. Also available are instructions for setting up SFTP.
Under no circumstances should PHI be sent unsecured, and Social Security numbers of Medicaid members should never be included in correspondence.
Files containing claim information and all self-disclosure correspondence from all sections of the form are to be submitted via SFTP to ensure Health Insurance Portability and Accountability (HIPAA) compliance.
Submitting Self-Disclosure by Mail
To submit a self-disclosure by mail, the mailing address is:
Audit and Overpayment
IHCP Program Integrity
P.O. Box 636297
Cincinnati, OH 45263-6297
The preferred method of submitting the self-disclosure form and supporting documents is via SFTP. If the provider chooses to mail these files instead, care must be taken to submit documentation in a HIPAA-compliant format via Certified Mail. Please do not mail documents without using appropriate encryption methods. Passwords to encrypted files must be emailed separately from the documentation or provided via telephone.
Remitting Payments
Providers should not submit payment with the self-disclosure form. The IHCP must first review the provider’s completed packet and validate the claims and overpayment amount. Before making any payment, the provider should wait for a letter that confirms the total amount owed. If the submitted form is complete and accurate, and depending on the number of claims to be validated, the confirmation letter is mailed typically within 14 business days. Incomplete forms and MCE disclosures will be returned by the IHCP, which could lead to referral for an audit.
After the IHCP reviews all disclosure submission material, the provider will receive notification indicating the final overpayment dollar amount and the procedure for remitting payment, if necessary. If submitting a check, be sure to note the audit number on the check.
If the submitted claim data does not materially match the IHCP payment data, or if the IHCP does not accept the provider’s self-disclosure results, the provider will receive correspondence with further instructions. Self-disclosure assumes that the provider has waived the right to administrative review and appeal.