Tip #5: Avoiding Medicaid Recoupments


The rules for Medicaid are esoteric. You practically need a J.D. to provide health care services for Medicaid recipients in North Carolina.  Some services require prior approval. Some services have caps on units billed per recipient in any given authorized period. Other services have restrictions on using concurrent services. For example:

Day Treatment services may not be provided during the same authorization period as the following services:

• MH/SA Targeted Case Management • Intensive In-Home Services; • Multisystemic Therapy; • Individual, group and family therapy; • Substance Abuse Intensive Outpatient Program; • Child Residential Treatment services–Levels II (Program Type) through IV; • Psychiatric Residential Treatment Facility (PRTF);• Substance abuse residential services; or • Inpatient hospitalization.

And if you make a mistake….Recoupment.  Whew! How is a provider supposed to know everything?

Answer: You can’t.

But, you can EDUCATE. If you are a provider with a mid to large size of employees (all of whom are filling out service notes and other documents that are mandatory to receive Medicaid payments), then you know the difficulty of ensuring each employee fills out the forms completely, correctly, and without cutting and pasting from the previous service note. (Yes, the State looks for this too).

Education can consist in multiple venues:

1.  Weekly meetings are great to talk about new Medicaid regulations or past mistakes made that need to be fixed.

2.  Another idea is to give one person, usually the office manager, the sole job to review each and every Implementation Update. Not all the Implementation Updates will apply to your particular health care service, but it is extremely important to keep up with any changes. Because, whether you are aware of the changes to Medicaid rules or not, the State will hold all new rules and regulations against you. Telling the State that you “didn’t know that was the rule,” is not a valid excuse.

3. Daily emails with tips.

4. Monthly staff meetings to provide all updates to Medicaid.

5.  Have someone from DHHS or a Medicaid attorney come to the main office and give a presentation.

6.  Attend all the State’s Medicaid conferences to keep up-to-date.

7.  Take 15 minutes each morning and Google NC Medicaid.

8.  Check for announcements on DHHS’ website daily.

9. Follow my blog (a little self-marketing never hurt anyone).

Staying up-to-date on all changes in Medicaid rules is extremely important. Because there are so many Medicaid rules, it is difficult to read and learn everything.  By engaging in some or all of the activities or suggestions enumerated above, providers can try to EDUCATE their employees…thus avoiding recoupment in the future.



About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on December 3, 2012, in Medicaid, Medicaid Funds, Medicaid Recoupment, Medicaid Reimbursement, North Carolina and tagged , , , , , , , . Bookmark the permalink. Leave a comment.

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