Current through Register Vol. 54, No. 44, November 2, 2024
(a) Except as
provided in subsection (b), if a provider discovers that the Department has
underpaid the provider under this part, or that a recipient has other coverage
for a service for which the Department has made a payment, the provider shall
be paid the amount of the underpayment or shall reimburse the Department the
amount of the overpayment according to the instructions in the provider
handbook.
(b) For payments to
providers that are subject to cost settlement, if either an analysis of the
provider's audit report by the Office of the Comptroller discloses that an
overpayment has been made to the provider or the provider advises the
Department in writing that an overpayment has occurred for a cost reporting
period ending on or after October 1, 1985, the following recoupment procedure
applies:
(1) The Office of the Comptroller
will issue a cost settlement letter to the provider notifying the provider of
the amount of the overpayment. The cost settlement letter will request that the
provider contact the Office of the Comptroller within 15 days of the date of
the letter to establish a repayment schedule. The date of the cost settlement
letter will count as day 1 in determining the 15-day response period to the
cost settlement letter and the repayment period for the overpayment. The
provider's timely written response to the cost settlement letter will be
determined by the postmark on the provider's letter or, if hand delivered, the
Department's date stamp.
(2) If the
provider does not submit an acceptable repayment plan to the Department or
fails to respond to the cost settlement letter within the specified time
period, the Department will offset the overpayment amount against the
provider's MA payments until the overpayment is satisfied.
(3) An acceptable repayment schedule includes
either direct payment to the Department by check from the provider or a request
by the provider to have the overpayment offset against the provider's Medical
Assistance payments until the overpayment is satisfied. To be acceptable, a
direct repayment or offset plan shall ensure that the total overpayment amount
is repaid to the Department by the date on which the Department is required to
credit the Federal government with the Federal share of the overpayment, not
including an administrative processing period that may be granted to the
Department under Federal procedures for completing the Medicaid expenditure
report. Direct repayment to the Department by check from the provider may be
made only in one lump sum payment. If the provider chooses the offset method,
the provider may choose to offset the overpayment in one lump sum or in a
maximum of four equal installments over the repayment period.
(4) If a provider chooses to make direct
repayment by check to the Department, but fails to repay by the specified due
date, the Department will offset the overpayment against the provider's MA
payments. If the provider chooses to repay by check but fails to do so as
agreed, the Department reserves the right to refuse to allow the provider to
elect a direct repayment plan, other than immediate direct repayment in
response to the cost settlement letter, if an overpayment is discovered for
subsequent cost reporting periods.
(5) Paragraphs (1)-(4) do not apply if the
provider is bankrupt or out-of-business and the debt is uncollectable under
section 1903(d)(2)(D) of the Social Security Act (42 U.S.C.A. §
1396(b)(2)(D)).
(6) An appeal by the provider of the action
by the Department to offset the overpayment against the provider's MA payments
when the provider fails either to respond timely to the cost settlement letter
or to pay the overpayment amount directly when due will not stay the
Department's action.
(7) Under
§
1101.84(b)(5)
(relating to provider right of appeal), an appeal by the provider of the audit
disallowance does not suspend the provider's obligation to repay the amount of
the overpayment to the Department. If the provider prevails in whole or in part
in an appeal and is thereby owed money by the Department, the Department will
refund to the provider monies due as a result of the provider's
appeal.
The provisions of this §1101.69 amended under sections 201
and 443.1 of the Public Welfare Code (62 P. S. §§
201 and
443.1).
This section cited in 55 Pa. Code §
1151.47 (relating to annual cost
reporting); 55 Pa. Code §
1163.452 (relating to payment
methods and rates); and 55 Pa. Code §
1181.69 (relating to annual
adjustment).
