Chapter 4: Evaluation Processes, Investigations, and Noncompliance Response

Self-Disclosure and Return of Overpayments

Two of the principles governing healthcare providers require them to self-monitor their compliance with various legal requirements and to self-report when they discover noncompliance.

First, the Department of Justice (DOJ) and Office of Inspector General (OIG) encourage self-disclosure if a provider discovers noncompliance with the Stark Law, Anti-Kickback Statute (AKS), False Claims Act (FCA), or Civil Monetary Penalties Law (CMP Law)—all four generally referred to as “fraud and abuse laws.”[2][3][4][5] DOJ and the OIG are the primary enforcement agencies. However, other enforcement agencies (such as state Medicaid and the Department of Defense) work closely with DOJ and the OIG to resolve self-disclosures. Therefore, reference to DOJ and the OIG in this article also generally includes any other government payor or enforcement agency.

Second, government payor rules (such as Medicare’s myriad payment guidelines and rules) require that providers submit accurate bills for payment. If any noncompliance with these payment guidelines is discovered (such that the provider may have received an overpayment from any government payor), then the provider is required to pay the requisite government payor(s) back. These two principles go hand in hand and are codified in statute, regulation, and various guidance. When an issue of potential noncompliance is discovered, then healthcare providers should work with counsel to determine whether to repay an overpayment or enter into either the OIG’s or the Centers for Medicare & Medicaid Services (CMS) Self-Disclosure Protocol.

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