What is Medicare credit balance?

A Medicare credit balance represents a Medicare overpayment to a provider due to patient billing error or claims processing error that must be refunded to Medicare.  The report is referred to as a Credit Balance Report because when a provider receives excess payment for a claim that was submitted, this is typically reflected in the provider’s accounting records (i.e., in the patient account receivable) as a “credit.”

What instances may give rise to a credit balance?

Different situations may give rise to a Medicare overpayment. For example:

• Paid twice by Medicare or may be paid by Medicare and by another insurer for the same service
• Incorrect calculation of patient deductible or patient coinsurance amount
• Paid for non-covered services
• Billed at incorrect daily rate

Which hospice agencies must file a Credit Balance Report?

If a hospice provider has more than one provider number, a separate report must be submitted for each provider number.  Providers who have a low utilization (i.e., determined by the intermediary that they should file a low utilization Medicare cost report) or who file less than 25 Medicare claims per year are not required to file a Medicare Credit Balance Report.

What does a credit Balance Report Consist of?

The Credit Balance Report consists of two pages. The first page is a Detail Page, where the hospice provider enters information about each credit balance, on a claim by claim basis. Once a claim has been reported on one Credit Balance Report it should not be reported again on a subsequent Credit Balance report. The second page is a Certification Page. All providers must complete the Certification Page.  The Detail Page is only required if the provider has credit balances to report.

The Detail Page

On this page, the provider must include detailed information about each Medicare claim with a credit balance, explanation  why the credit balance arose, and indicate whether the credit balance is being repaid with the filing of the report.  

The Certification Page

The second page of the Credit Balance Report is a certification page. Facilities that do not have any credit balances in a quarter are only required to submit the signed certification page. There are key areas of this page.

• The first area serves as a reminder that there is a requirement to file a Credit Balance Report and failure to file this report will result in suspension of Medicare payments. Further, any misrepresentations may lead to fines and further penalties
• The second area requires an officer or administrator of the hospice agency to sign a certification that that Credit Balance Report is true and accurate
• The third area requires a selection from one of three choices: (i) provider qualifies as Low Utilization Provider (ii) Detail Page included with Report (iii) no credit balances to report

When is the report due?

A hospice provider must assess any Medicare credit balances on a quarterly basis and must report any identified Medicare credit balances within 30 days of the end of each calendar quarter. The Medicare Credit Balance Report due dates are as follows:

What happens if a provider fails to submit a Credit Balance Report?

Failure to submit a Credit Balance Report by the 15^th calendar day after the report due date will result in a Suspension Warning letter. If the completed report is not received within 15 calendar days from issuance of the letter, Medicare payments to the provider are suspended under a completed letter is received, accepted, and processed.

Where can you find a Credit Balance Report form?

The Credit Balance Report that must be completed and submitted is Form CMS-838, which can be found here: Medicare Credit Balance Form (pdf)