This year’s OIG report includes priorities for finding fraud and waste in Medicare, which continues to include imaging services.

Bottom line, your diagnostic radiology group’s medical practice billing is under closer examination.

If there was ever a time when you needed a healthcare revenue cycle management team that understands the nuances of radiology billing, coding and collections, it’s now, when CMS is increasing audits resulting from overpayments. The federal government’s goal is to cut the Medicare FFS improper payment rate by half and reduce overall payment errors by $50 billion nationwide.

OIG is reviewing Medicare payments for high-cost diagnostic radiology tests to determine whether they were medically necessary and the extent to which the same diagnostic tests are ordered for a beneficiary by primary care physicians and physician specialists for the same treatment. Medicare will not pay for items or services that are not “reasonable and necessary.”

The devil is in the details, and in the documentation. Make no bones about it; niche specialization in radiology coding can ensure proper and detailed documentation to help you reduce the risk of overbilling and high paid claim error rates.

When it comes to overpayments, there are many questions that arise and answers need a legal perspective. Polsinelli law firm’s attorneys Jeffrey Fitzgerald, Esq. and Asher Funk, Esq. address some commonly asked questions applicable to all medical specialties.

Is there a duty to repay overpayments to Medicare?

Yes. An overpayment is defined as any funds that a “person” (enrolled Medicare provider or supplier) receives or retains under Title XVIII or XIX to which the person, after applicable reconciliation, is not entitled under such title.

Any overpayment retained after the deadline for reporting and returning is an “obligation” (as defined by the False Claims Act or FCA). FCA liability exists when knowingly concealing or knowingly and improperly avoiding or decreasing an obligation to pay or transmit money or property to the government (31 U.S.C. 3729(a)(1)(G).

Who has to make the repayment?

The entity that receives the Medicare/Medicaid payment has the duty to repay.

According to the Patient Protection and Affordable Care Act (“PPACA”) Section 6402:

  • If a person has received an overpayment, that person shall:
  • Report and return the overpayment
  • Notify the Secretary, … in writing of the reason for the overpayment
  • The overpayment must be reported and returned by the later of
  • The date which is 60 days after the date on which the overpayment was identified; or
  • The date any corresponding cost report is due, if applicable

If there is a potential overpayment, how far back should we audit?

When did the problem start? Factually speaking, is it based on a change in a billing system or software, or on HR changes or employee conduct? Can you go back and pinpoint a time frame based on these factual changes? If not, then look at the legal limits.

If there is no factual limit, look at the legal limits:

  • Medicare claims reopening: 4 years (42 C.F.R. 405.980(b), 42 U.S.C. 1395ff(b)(1)(G))
  • Revisions to overpayment “recovery” period in the American Taxpayer Relief Act of 2012 do not require longer look-back period (extended recovery period from three years to six years (42 U.S.C. 1395gg(b))
  • False Claims Act: 6 years

NOTE OF DISCLAIMER: This blog is for general informational use only. Please consult with your legal counsel and/or the experts at for advice specific to your diagnostic radiology practice. is the results-proven alternative for physician medical billing, with a niche specialization in diagnostic radiology coding and billing that generates unprecedented results and builds profitable medical practices. Leveraging a history of industry wide success spanning 25 years, partners with medical practices throughout the U.S. to optimize revenue for hospital based and community based physicians. For more information, visit

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