Tip #8: Avoiding Medicaid Recoupments

After talking with the Office of Administrative Hearings (OAH) today and learning that, in the past 30 days, there have been 15,000 Medicaid appeals filed, I realized how important these Tips to Avoid Medicaid Recoupment may be. Granted, I am sure most of those Medicaid appeals are Medicaid recipients appealing denials of services, but, still, that is a lot of appeals!!

Tip #8: Always keep every revised version of whichever DMA Clinical Policy applies to your practice.

For example, if you provide orthodontia services to Medicaid recipients, then you should have every version of Clinical Policy 4B, starting when you started providing orthodontia services until the present.

If you have not this, never fear, you can go to The WayBack Machine, a website that keeps an archive of certain websites, including the material found on the website at different time periods. The WayBack Machine has archived the NC DMA websites over time.

Keeping every revised version of the applicable Clinical Policy will help health care providers avoid Medicaid recoupments, IF, and only IF, each time a new revised version is published, go through both the replaced version and the newly updated version page by page. Compare the old version to the new version. Find every word that was changed or sentence that was added, or additional criteria added. Highlight, on the new version, all the additional words. On the new version, mark where words or sentences have been deleted.

Doing this exercise will do two things: (1) the health care provider will be intimately knowledgable about the Clinical Policy (which is always helpful); and (2) the health care provider will know which sections or criteria were most important to the State. Wherever a change occurred, it is due to something.  Usually you can figure it out.  For example, if the new version of Clinical Policy 4B requires an additional criterion of the Medicaid recipient, in order to receive braces, to demonstrate a mental health diagnosis caused by crooked teeth (I’m  making this up), then one could deduce that too many Medicaid recipients received braces in the past and that the State is trying to make it more difficult to receive braces.

Highlighting the changes in the new policies will help health care providers proactively avoiding Medicaid recoupments because the health care provider will understand each new criterion or hoop to jump through for the upcoming Medicaid claims.

However, doing this exercise will also help the health care provider who has received an audit and received the Tentative Notice of Overpayment claiming the provider owes money to the State. This is how: The Medicaid audits are auditing claims from 2009-2010 (usually). The Clinical Policies have changed immensely over the years.  Many policies are more stringent now than in the past.  The people conducting the Medicaid audits, often, in my experience, audit the health care provider with the current Clinical Policy in place now, not the Clinical Policy from the applicable time period.  This results in incorrect audits and incorrect results.

Know the policies. Know the changes to the policies. Avoid Medicaid recoupments.

 

About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on January 23, 2013, in Clinical Policy No. 4B, DHHS, Division of Medical Assistance, Health Care Providers and Services, Medicaid, Medicaid Appeals, Medicaid Recipients, Medicaid Recoupment, North Carolina, OAH, Orthodontia Services, Tentative Notices of Overpayment, Tips to Avoid Medicaid Recoupment and tagged , , , , , , , . Bookmark the permalink. 2 Comments.

  1. Russell Semon

    Did I miss 1-7 ? Thanks for 8-11.

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