Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1101 - GENERAL PROVISIONS › FEES AND PAYMENTS › Section 1101.69 - Overpayment-underpayment

Current through Register Vol. 54, No. 28, July 13, 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.