The State contracted with PCG (a consulting group) to review Medicaid payouts to health care providers providing community support, community support team, and personal care services to Medicaid recipients in 2010. The health care provider receives a letter called “The Tentative Notice of Overpayment,” which states the amount owed to the State. Frequently, the amounts are in the hundreds of thousands of dollars.

The tip today is: Remember to read all the Implementation Updates and Medicaid manuals from the time period which is at issue. The rules and regulations have changed drastically over the years.  For example, if the Notice of Overpayment covers January 2010 through June 2010, the 2012 rules will not apply.

An example in which reading all the pertinent Implementation Updates for the relevant time is as follows:

PCG tells Health Care Provider ABC (“ABC”) that ABC must pay back $450,000 for Medicaid services provided to Medicaid recipients for community support team services in January through June 2010.  90% of PCG’s alleged document deficiencies found is due to the Person Centered Plan (“PCP”) being signed prior to the comprehensive assessment. Obviously, Medicaid rules state that the assessment must occur prior to any PCP.

However, NOT in 2010! In early 2010, DHHS drafted Implementation #68, which stated that health care providers would no longer use an Introductory PCP. Remember those? An Introductory PCP was drafted prior to the assessment. An Intro PCP was extremely basic and really just gave little information regarding contacts and a brief overview of the Medicaid recipeints’ issues. But, importantly, the Intro PCP was signed prior to the assessment, unlike now.

So when PCG cited these 90% of errors because ABC’s documentation was misdate; and, therefore ABC must return Medicaid monies, PCG failed to read Implementation Update #68. Back in 2010, a PCP could be signed prior to an assessment (an Intro PCP). So, actually, all the “errors” were not errors. And ABC was saved from owing $450,000 to the State.

The morale? READ THE IMPLEMENTATION UPDATES FROM THE RELEVANT TIME PERIOD!!!