Notice: This CMS-approved document has been submitted - Philips ...

CMS-1403-FC
believe that a final adverse action may preclude payment,
and thus, establish an overpayment from the date of the
adverse action. As such, we believe that physician and NPP
organizations and individual practitioners should not be
allowed to retain any reimbursement they receive after the
final adverse action.
In addition, we added the word “final” to the
beginning of the term “adverse legal action” in the
regulation text in §424.535 on overpayment. We define the
term as a “final adverse action” in the definition section
at §424.502 and want to be consistent with that definition.
Also, we want to be consistent with our definition of this
term in the Durable medical Equipment prosthetics Orthotics
and Supplies surety bond rule (CMS-6006-F). Moreover, we
want this term to be consistent with the definition of
“final adverse action” found in section 221(g)(1)(A) of the
Health Insurance Portability and Accountability Act (HIPAA)
of 1996. Finally, we believe that a final adverse action
has occurred when the sanction is imposed and not when a
supplier has exhausted all of the appeal rights associated
with the action itself.
We believe that it is essential that this type of
change be reported in a timely manner (that is within
30 days). For example, if CMS or our designated contractor
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