What Is the Medicare Statute of Limitations?

Law reports on bookshelves

The Medicare Statute of Limitations is simply an extension of the dates for auditing purposes. The government has discovered that in order to recover non-fraudulent over billing, for example, additional time to examine records is needed. Critics note that increasing the statute to five years for criminal cases and six for civil cases instead of three will place a burden on healthcare providers. The Office of the Inspector General says that the additional two years will mean that more overpayments can be recovered via audits. Overall, this law will only affect medical providers and should not adversely affect patients – unless in the case of third party insurance use in conjunction with Medicare. What does this mean for you? Here’s a more detailed look at what is the Medicare statute of limitations.

On 10 July 2013, a new, non-retroactive Medicare statute of limitations came into effect, which means it only affects cases where services were rendered on or after this date. Prior to this limitation, the United States, officer, or agency had only three years to file any complaints and collect overpayments, but the benchmark has now been moved to five years for criminal cases (18 U.S.C. § 3282), and six years for civil cases (42 U.S.C. § 1320a-7a(c)(1)). 

This statute affects non-fraudulent Medicare overpayments as well as some criminal cases. However, since the auditing process is such a lengthy one, auditors realized that there were as much as $332 million in overpayments that couldn’t be handled because time had already passed. On the other hand, for medical providers, this statute is problematic when auditing files up to half a decade old.

Civil Monetary Penalties, U.S. Code, Title 42, Subchapter XI, Part A, § 1320a–7a

The law on Improperly Filed Claims notes anyone – or a body such as an organization, agency, or entity – who knowingly submits a false claim, which results in incorrectly billed Medicare payments or overpayment is fraudulent. Furthermore, if services were given by an unlicensed medical professional (non-physician) or someone not medically certified and a service was billed as if it was administered by a doctor then that is also fraudulent. If items are incorrectly dated or the patient wasn’t eligible for Medicare, it’s fraudulent. If items are performed (or said they are performed) that aren’t medically necessary, then those actions are fraudulent. In each of the above cases, those committing fraud may be subject to civil monetary penalties. 

Other penalty-inducing cases include:

  • A person who knowingly presents a request for payment that violates Medicare’s terms of agreement such as overcharging for a service.
  • A person who knowingly gives misleading information to inpatient hospital services, causing the patient to be discharged from the hospital.
  • A provider participating in the Medicaid program who is excluded from participation.
  • A provider who offers to pay individuals for being able to use their Medicare number and falsely billing for services.
  • A provider who arranges contracts with people who should be excluded from participation.
  • A provider who knowingly makes, uses, or causes false records or statements to obtain payment of items.
  • A provider who fails to allow the Inspector General of the Department of Health and Human Services to have access to file for auditing purposes.
  • A provider who makes false statements, omits, or misrepresents material facts in the application, bid, or contract to receive additional payment.
  • A provider who knows of an overpayment but doesn’t report it.
  • Unreported overpayments will be subject to penalties not more than $10,000 for each service item, or $15,000 for each individual to whom false or misleading information was given, or $10,000 for each day the prohibited relationship occurs or $50,000 for each act of false record or statement.

The Secretary may determine that the person may no longer participate in Federal health care programs.

Payments to induce reduction or limitation of services note that if a hospital makes a payment to a physician to limit or reduce services to people entitled to Medicare, then the hospital can be fined $2,000 for each individual. If a physician knowingly accepts receipt of payment, then that physician may be subject to a $2,000 fine per patient or up to $5,000 or three times the amount of the payments.

Offenses Not Capital, U.S. Code, Title 18, Chapter 213, § 3282

This law notes that unless otherwise stated by law, no person shall be prosecuted, tried, or punished for offense, not capital unless the indictment within five years of the offense’s date of commitment.

The SMART Act for Secondary Payer Statute

The Medicare Secondary Payer Law created several decade’s worth of problems, so the SMART Act was passed to determine the payment procedures for treating Medicare beneficiaries when a third party is responsible for covering medical costs. Medicare then becomes a secondary source of payment and a third party would be a primary form of payment for services. The private party may be health insurance, auto insurance, worker’s compensation, or any medical costs resulting from a settlement.

What If I Discover Fraudulent Overpayment?

The Medicare Statute of Limitations aims to recover overpaid funds that are non-fraudulent, but the government is also interested in recovering fraudulent use of Medicare funds. And that’s where relators come in, people who blow the lid on the misuse of funds, called whistleblowers. If you suspect that your organization is guilty of mishandling funds or if you as a patient notice that your Medicare MSN statements don’t quite add up, contact a trusted attorney.

Coxwell & Associates, PLLC has over 36 years of experience dealing with fraudulent Medicare claims, and we are here to help you. Federal law protects those who report fraud and recover government funds from repercussions – and you may even be eligible for monetary compensation. We have created a guide which includes everything you need to know about Qui Tam and whistleblowing lawsuits. Click on the button below to download your free guide and start your journey to become a whistleblower.

Disclaimer: This blog is intended as general information purposes only, and is not a substitute for legal advice. Anyone with a legal problem should consult a lawyer immediately.

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