Medicare - Unrestricted Reopening



By: Gary R. Street, D.C., Ph.C., F.I.C.A., F.P.A.C., L.C.P. (Hon)





A section in the Medicare Carrier's Manual (MCM) is being printed 
as a reminder to providers that carriers may pursue claim refunds 
"at any time" under specific circumstances. You must review 
Medicare materials carefully and share it with your staff. The MCM 
section is: 12100.10 Unrestricted Reopening.



A determination or decision may be reopened at any time if it was 
procured by fraud or similar fault, regardless of whether criminal 
prosecution has been or will be instituted. The fraud or similar fault 
may be that of the beneficiary, provider, physician, or any other 
person. It includes:



deception by a person who knows the the deception may result in 
unauthorized benefits to someone;



an act which approximates fraud, i.e., the furnishing of information 
which the individual knows is incorrect or incomplete, or the 
deliberate concealment of information, with or without a judicial 
finding of fraud;



a pattern of program abuse by physicians, resulting from practices 
that are inconsistent with accepted sound fiscal, business, or 
medical practice, such as:



a) the furnishing of services in excess of the individual's needs, or 
of a quality that does 



not meet professionally recognized standards of health care; or



b) the submittal of incorrect, incomplete or misleading 
information that results in payment 



for services;



1. that were not furnished;



2. that were more expensive than those furnished;



3. that were not furnished under the conditions indicated on the 
bill.



c) the submittal of, or causing the submittal of, bills or requests 
for payment containing 



charges for Medicare patients that are substantially in excess of 
the amounts the 



physician customarily charges.



an act or pattern of program abuse involving collusion between the 
supplier and the recipient that results in higher costs or charges to 
the program.



any act that constitutes fraud under Federal or State law.







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