CMS Pub. 100-06, ch. 3, § 80

There are special rules that apply when an overpayment is discovered subsequent to the fifth year

following the year in which notice was sent that the amount was paid. Ordinarily, the provider or

beneficiary will be considered without fault unless there is evidence to the contrary. In the absence of

evidence to the contrary, the contractor will not demand and recover the determined overpayment. (One

example of evidence to the contrary would be a pattern of billing errors. See Medicare Program Integrity

Manual, Publication (PIM) 100-08, Chapter 3.)

EXAMPLE 1: On May 9, 2016 Dr. A is notified that he has been paid $1005.00 for services provided

to Mr. Smith, beneficiary. On January 6, 2022 the contractor determines that Dr. A was overpaid for the

services to Mr. Smith, beneficiary. The contractor will not recover this overpayment as long as there is

no evidence to the contrary because it was determined subsequent to the fifth year after notification of

payment. (Any determination date on or after Jan. 1, 2022 will not be recovered.)(If evidence to the

contrary existed, recoupment may be initiated. The PIM should be referenced and if necessary the

appropriate Benefits Integrity unit at the contractor for guidance.)

EXAMPLE 2: On May 9, 2016 Dr. A is notified that he has been paid $1005.00 for services provided

to Mr. Smith, beneficiary. On September 20, 2019 the contractor determines that Dr. A was overpaid for

the services to Mr. Smith, beneficiary. The contractor will attempt recovery of the overpayment. (Any

determination dates up to and including Dec. 31, 2021 will be recovered.)