Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part I - Per Diem Methodology › Section 12VAC30-70-80 - Refund of overpayments

Current through Register Vol. 40, No. 24, July 15, 2024
A. Lump
				  sum payment. When the provider files a cost report indicating that an
				  overpayment has occurred, full refund shall be remitted with the cost report.
				  In cases where DMAS discovers an overpayment during desk review, field audit,
				  or final settlement, DMAS shall promptly send the first demand letter
				  requesting a lump sum refund. Recovery shall be undertaken even though the
				  provider disputes in whole or in part DMAS's determination of the
				  overpayment.
B. Offset. If the
				  provider has been overpaid for a particular fiscal year and has been underpaid
				  for another fiscal year, the underpayment shall be offset against the
				  overpayment. So long as the provider has an overpayment balance, any
				  underpayments discovered by subsequent review or audit shall also be used to
				  reduce the remaining amount of the overpayment.
C. Payment schedule. If the provider cannot
				  refund the total amount of the overpayment (i) at the time it files a cost
				  report indicating that an overpayment has occurred, the provider shall request
				  an extended repayment schedule at the time of filing, or (ii) within 30 days
				  after receiving the DMAS demand letter, the provider shall promptly request an
				  extended repayment schedule.
DMAS may establish a repayment schedule of up to 12 months
					 to recover all or part of an overpayment or, if a provider demonstrates that
					 repayment within a 12-month period would create severe financial hardship, the
					 Director of the Department of Medical Assistance Services (the "director") may
					 approve a repayment schedule of up to 36 months.
A provider shall have no more than one extended repayment
					 schedule in place at one time. If an audit later uncovers an additional
					 overpayment, the full amount shall be repaid within 30 days unless the provider
					 submits further documentation supporting a modification to the existing
					 extended repayment schedule to include the additional amount.
If, during the time an extended repayment schedule is in
					 effect, the provider withdraws from the Program or fails to file a cost report
					 in a timely manner, the outstanding balance shall become immediately due and
					 payable. When a repayment schedule is used to recover only part of an
					 overpayment, the remaining amount shall be recovered by the reduction of
					 interim payments to the provider or by lump sum payments.
D. Extension request documentation. In the
				  request for an extended repayment schedule, the provider shall document the
				  need for an extended (beyond 30 days) repayment and submit a written proposal
				  scheduling the dates and amounts of repayments. If DMAS approves the schedule,
				  DMAS shall send the provider written notification of the approved repayment
				  schedule, which shall be effective retroactive to the date the provider
				  submitted the proposal.
E. Interest
				  charge on extended repayment. Once an initial determination of overpayment has
				  been made, DMAS shall undertake full recovery of such overpayment whether or
				  not the provider disputes, in whole or in part, the initial determination of
				  overpayment. If an appeal follows, interest shall be waived during the period
				  of administrative appeal of an initial determination of overpayment.
Interest charges on the unpaid balance of any overpayment
					 shall accrue pursuant to § 32.1-313 of the Code of Virginia from the date
					 the director's determination becomes final.
The director's determination shall be deemed to be final
					 on (i) the due date of any cost report filed by the provider indicating that an
					 overpayment has occurred, or (ii) the issue date of any notice of overpayment,
					 issued by DMAS, if the provider does not file an appeal, or (iii) the issue
					 date of any administrative decision issued by DMAS after an informal fact
					 finding conference, if the provider does not file an appeal, or (iv) the issue
					 date of any administrative decision signed by the director, regardless of
					 whether a judicial appeal follows. In any event, interest shall be waived if
					 the overpayment is completely liquidated within 30 days of the date of the
					 final determination. In cases in which a determination of overpayment has been
					 judicially reversed, the provider shall be reimbursed that portion of the
					 payment to which it is entitled, plus any applicable interest which the
					 provider paid to DMAS.
Statutory Authority
§ 32.1-325 of the Code of Virginia and Item 322 J
						of Chapter 912 of the 1996 Virginia Acts of Assembly.