The standard for an “identified overpayment” under Medicare Parts A–D now aligns with section 1128J(d)(4)(A) of the Social Security Act, which incorporates by reference the Federal False Claim Act’s (the “FCA”) “knowledge” standard. The previous “reasonable diligence” standard, which, as it related to Part C, had been struck down by a Federal court, no longer applies. Under the new standard, a provider, supplier, or Medicare Advantage Organization (“MAO”) has knowledge of an overpayment when it has been identified.

Additionally, the deadline for reporting and returning identified overpayments has also been finalized. An overpayment must be reported and returned by the later of:

1. The date which is 60 days after the date on which the overpayment was identified, or
2. The date any corresponding cost report is due, if applicable.

Any identified overpayment retained after the deadline to report and return may create FCA liability.

The foregoing was finalized, as proposed in 2022, pursuant to the Calendar Year 2025 Physician Fee Schedule (the “2025 PFS”). With respect to the timeframe to report and return overpayments, the 2025 PFS suspends a person’s 60-day obligation to report and return overpayments for up to 180 days if the person, after having identified an overpayment, conducts a timely, good-faith investigation to determine whether related overpayments exist. While the 2025 PFS did not expressly define the term “good-faith investigation”, persons “can rely upon [its] plain meaning.” See 2025 PFS at 98338.

Takeaways

This legal change creates new risks for providers who fail to investigate credible information about a potential overpayment. However, this should come as no surprise, as it aligns with what the U.S. Department of Justice may already pursue against a person under the FCA—a reverse false claim. As noted in the commentary of the 2025 PFS, the FCA, from which the “knowledge” qualifier originates, contains an existing body of case law and examples to guide stakeholders and their counsel regarding if a person has the requisite knowledge to have identified an overpayment based on the facts and circumstances presented. See 2025 PFS at 98335–8.

Additionally, once a person has identified an overpayment, the 60-day obligation to report and return such overpayment begins to run. And, that deadline exists regardless of whether the overpayment has been quantified. But, because quantification takes time, the 60-day deadline may be suspended if the person needs to dive deeper into its investigation to determine if related overpayments exist. The timeline to do so, however, is only 180 days. Thus, providers should make every effort to act with “all deliberate speed”, which, in turn, may require providers with fewer resources and expertise to expend a disproportionately high amount of effort. These rules apply across all of Medicare and, thus, are applicable to all providers, suppliers, and MAOs.