(a) Terminology. For purposes of this section—
Applicable reconciliation occurs on the date of the annual final deadline for risk adjustment data submission described at § 422.310(g), which is announced by CMS each year.
Funds means any payment that an MA organization has received that is based on data submitted by the MA organization to CMS for payment purposes, including § 422.308(f) and § 422.310.
Overpayment means any funds that an MA organization has received or retained under title XVIII of the Act to which the MA organization, after applicable reconciliation, is not entitled under such title.
(b) General rule. If an MA organization has identified that it has received an overpayment, the MA organization must report and return that overpayment in the form and manner set forth in this section.
(c) Identified overpayment. The MA organization has identified an overpayment when the MA organization knowingly receives or retains an overpayment. The term “knowingly” has the meaning set forth in 31 U.S.C. 3729(b)(1)(A).
(d) Reporting and returning of an overpayment. An MA organization must report and return any overpayment it received no later than 60 days after the date on which it identified it received an overpayment, unless otherwise directed by CMS for purposes of § 422.311.
(1) Reporting. An MA organization must notify CMS, of the amount and reason for the overpayment, using a notification process determined by CMS.
(2) Returning. An MA organization must return identified overpayments in a manner specified by CMS.
(e) Enforcement. Any overpayment retained by an MA organization is an obligation under 31 U.S.C. 3729(b)(3) if not reported and returned in accordance with paragraph (d) of this section.
(f) Look-back period. An MA organization must report and return any overpayment identified for the 6 most recent completed payment years.
[79 FR 29958, May 23, 2014, as amended at 89 FR 98565, Dec. 9, 2024]
Notes of Decisions
United States v. United Healthcare Ins. Co., 848 F.3d 1161 (9th Cir. 2016).
“Also in 2014, CMS adopted a regulation stating that a Medicare Advantage organization "has identified an overpayment when [it] *1170 has determined, or should have determined through the exercise of reasonable diligence, that [it] has received an overpayment,” 42 C.F.R. §…”
UnitedHealthcare Ins. Co v. Xavier Becerra, 9 F.4th 868 (D.C. Cir. 2021).
· cites it 4× “See 42 C.F.R. § 422.326 . As relevant here, the Overpayment Rule establishes that, if a Medicare Advantage insurer has received a payment increment for a beneficiary’s diagnosis and discovers that there is no basis for that payment in the underlying medical records, that is an…”
Graves v. Plaza Med. Centers, Corp., 276 F. Supp. 3d 1335 (S.D. Fla. 2017).
· cites it 2× “7654 -01 (“[E]ven without this final rule, providers and- suppliers are subject to the statutory requirements found in [42 U.”
UnitedHealthCare Ins. Co. v. Price, 255 F. Supp. 3d 208 (D.D.C. 2017).
“BACKGROUND In this matter, United seeks review of an administrative rule, promulgated in 2014 and codified at 42 C.F.R. § 422.326 (the 2014 Overpayment Rule), that applies to insurers participating in the Medicare Advantage (MA) program.”
United States v. United Healthcare Ins. Co, 832 F.3d 1084 (9th Cir. 2016).
“Also in 2014, CMS adopted a regulation stating that a Medicare Advantage organization “has identified an overpayment when [it] has determined, or should have determined through the exercise of reasonable diligence, that [it] has received an overpayment,” 42 C.F.R. § 422.326 (c),…”
UnitedHealthcare Ins. Co. v. Xavier Becerra (REISSUE) (D.C. Cir. 2021).
· cites it 4× “See 42 C.F.R. § 422.326 . As relevant here, the Overpayment Rule establishes that, if a Medicare Advantage insurer has received a payment increment for a beneficiary’s diagnosis and discovers that there is no basis for that payment in the underlying medical records, that is an…”
Unitedhealthcare Ins. Co. v. Burwell, 248 F. Supp. 3d 192 (D.D.C. 2017).
· cites it 3× “CMS proposed a new regulation, 42 C.F.R. § 422.326 , titled “Reporting and Returning Overpayments,” that was intended to “clarify the statutory definition of overpayment.”
Unitedhealthcare Ins. Co. v. Burwell (D.D.C. 2018).
· cites it 2× “6 CMS proposed to “clarify the statutory definition of overpayment” with a new regulation titled “Reporting and Returning Overpayments,” to be codified at 42 C.F.R. § 422.326 . See 79 Fed. Reg. at 1996, 2055-56 (June 29, 2000) (AR80 at AR139-40).”
United States v. United Healthcare Ins. Co (9th Cir. 2016).
“4 Also in 2014, CMS adopted a regulation stating that a Medicare Advantage organization “has identified an overpayment when [it] has determined, or should have determined through the exercise of reasonable diligence, that [it] has received an overpayment,” 42 C.F.R. § 422.326…”
United States v. United Healthcare Ins. Co (9th Cir. 2016).
“4 Also in 2014, CMS adopted a regulation stating that a Medicare Advantage organization “has identified an overpayment when [it] has determined, or should have determined through the exercise of reasonable diligence, that [it] has received an overpayment,” 42 C.F.R. § 422.326…”
Kuriyan v. HCSC Ins. Servs. (D.N.M. 2020).
“42 C.F.R. § 422.326 (a). quarterly reports and review reports for evidence of “suspicious activity, Fraud and Abuse cases, return on investment, cost avoidance, adverse events and other information as directed by HSD.”
United States of Am. ex rel. Uri Bassan v. Omnicare, Inc. (S.D.N.Y. 2021).
“3d at 1061; see also 42 C.F.R. § 422.326 (a). For our purposes, there is no need to scrutinize the exact dates of payment submissions, because the complaint more than sufficiently alleges that Omnicare had notice of its violations and thus that it needed to repay the…”
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