Total invoice price is the net amount a provider pays for an item/service, taking into account ALL discounts, rebates, refunds, or other adjustments.

To clarify, it is the provider’s obligation to report and return any additional amount received in the form of discounts, rebates, refunds, or other adjustments for an item/service if previously billed to and reimbursed by Medicare under Parts A or B.

A common example would be a provider reporting and billing Medicare for total invoice price on an item/service resulting in Medicare payment, only to receive rebate dollars after Medicare payment. The additional rebate dollars received, yet not accounted for in the original total invoice price billed on a claim, is therefore considered by Medicare to be an “overpayment”.

It is the provider’s obligation to report all overpayments and voluntarily refund the overbilled amount.

Noridian provides opportunities for provider self-disclosure and return of overpayments via Voluntary Checks Form - Non-MSP (access under ‘Overpayment/Recoupment’ forms).

To return an overpayment, the provider must:

1. Include on the Form the beneficiary’s name and DCN number found on the claim that received the overpayment.
2. Choose a Reason Code for Claim Adjustment-#13 (Other)
3. In the “Other” box, include the information per claim:

Rebate- CPT/HCPCs Code XXXXX; Original Invoice Price $XXX; Corrected Invoice Price $XXX; refund $XXX

In summary, Noridian understands that the return of overpayments may be an added burden for providers. However, neither timing of the rebate nor the form or type of program in which the rebate is presented affects Medicare’s expectation that the rebate must be passed on to the Medicare program as set forth by regulation.

It is ultimately up to the provider to determine whether to participate in a rebate program and thus accept any related regulatory obligations (including the return of any amount due its Medicare patients). See 42 C.F.R. § 1001.952.

References

• Medicare and Medicaid Program Integrity Provisions Section 1128J. [42 U.S.C. 1320a-7k] (a)
• Code of Federal Regulations 2015, Title 42, Volume 5, Section 1001-952
• U.S. Code 2020, Title 42, Chapter 7, Subchapter XI, Part A, Section 1320a
• The Provider Reimbursement Manual - Part 1, 15-1, Chapter 8, Section 804
• Medicare Fraud & Abuse: Prevent, Detect, Report
• Medicare Overpayments