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Protocol for Voluntary Self-Disclosure of Provider Overpayments

The Indiana Health Coverage Programs (IHCP) has established a self-disclosure protocol for providers that need to report Medicaid and Children's Health Insurance Program (CHIP) fee-for-service (FFS) 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 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 IHCP, the Centers for Medicare & Medicaid Services (CMS), the Office of Inspector General (OIG), other state or federal agencies, or other investigative entities.

Failure to complete and submit the Voluntary Self-Disclosure of Provider Overpayments Packet (linked at the bottom of this webpage), 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 (PPACA). 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. Should you need to report managed care overpayments, please 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.

Providers should use the self-disclosure protocol to report the following, but 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. Please report IHCP claim-processing payment 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 Part II, Section 5 of the Voluntary Self-Disclosure of Provider Overpayments Packet.

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.sur@fssa.in.gov.

Provider Responsibilities

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 you're 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."

An electronic form is available in PDF format at the bottom of this webpage for providers to download, complete, and submit (along with the repayment, if paying by check) to the following address:

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

Files containing claim information and all self-disclosure correspondence from all sections of the packet are to be submitted in an electronic Health Insurance Portability and Accountability Act (HIPAA)-compliant format (via encrypted CD, DVD or other similar format) to the address listed above. Documentation/information shall be submitted in a HIPAA-compliant and secure manner. Please do not email or mail documents without using appropriate encryption methods. Passwords to encrypted files shall be emailed separately from the documentation or data or provided via telephone.

The provider shall submit a copy of the packet electronically via secured email to programintegrity.sur@fssa.in.gov. If the provider does not have secure email capability, then the provider can send an email without any protected health information (PHI) or attachments and request a secured email be sent to the provider. The Office of Medicaid Policy and Planning (OMPP) will then send a secure email to the provider that the provider then can use to submit PHI. Under no circumstances should PHI be sent unsecured and never include Social Security numbers of Medicaid members. All PHI violations shall be reported in accordance with law and regulation.

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 utilize 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 utilized and how the overpayments were discovered.

To avoid overpayments being included in subsequent Program Integrity audits, providers should request claim adjustments as soon as overpayments are identified by internal audit procedures.

After the IHCP 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 IHCP 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.

Access the Voluntary Self-Disclosure of Provider Overpayments Packet

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