Recovery
of Payment Errors
Reimbursements to providers which are later found to be
made in error are resolved in one of three ways:
·
MCO recovers
inappropriate payments or payments in error to a provider;
·
MCO does not
recover inappropriate payments or payments in error to a provider and BWC
recovers payment error from MCO
·
MCO does not
recover inappropriate payments or payments in error to a provider and is not
responsible for payment
Payment
Errors Recoverable from Provider
The MCO
collects/recovers inappropriate payments or payments made to providers in
error. In the event reimbursement is made in excess or in error to a provider,
the MCO may, where appropriate, recover reimbursement from that provider in the
following manner:
·
MCO will
deduct reimbursements made in excess or in error from future reimbursements due
to the provider or;
·
Require the
provider to refund the reimbursements to the MCO, for overpayments made in
excess or in error, within 10 business days of expiration of appeal period or
notification of bill dispute resolution;
·
Require the
provider to void and return the uncashed check to the MCO.
Recovery
of reimbursement made in excess or in error is limited to bills within two
years from the date of bill adjudication except in cases investigated by the
BWC Special Investigations department.
Reimbursements
made in excess or in error which may be recovered from the provider include but
are not limited to:
·
Reimbursement
made for services/supplies that were clearly not allowed per BWC rule in effect
on the date of service.
·
Reimbursement
made for services/supplies that are not related to the treatment of the allowed conditions.
·
Reimbursement
made more than once for the same covered services/supplies.
·
Reimbursement
made for services/supplies in excess of the billed amount or fee maximum.
·
Reimbursements
made incorrectly due to coding or billing errors.
·
Reimbursement
accepted inadvertently or incorrectly.
·
Reimbursement
made for services/supplies that are later deemed medically unnecessary through
BWC’s or MCO’s ADR process.
·
Reimbursement
made for services/supplies that were specifically denied in a claim on the date
of service.
·
Reimbursement
made in which documentation does not support the provision of services and/or
supplies.
·
Reimbursement
for a treated and billed condition that is not medically necessary for the
allowed condition per standard guidelines; i.e.; InterQual, Milliman and
Robertson, Mercy Guidelines or other BWC approved guidelines utilized by the
MCO.
·
Reimbursement
for the total hospital admission when it is not medically necessary for allowed
condition per standard guidelines; i.e.; InterQual, Milliman and Robertson, or
other BWC approved guidelines utilized by the MCO.
·
Reimbursement
for a portion (room charges and/or services) of the length of stay was not
medically necessary per standard guidelines; i.e.; InterQual, Milliman and
Robertson, or other BWC approved guidelines utilized by the MCO.
Steps
to Recover Reimbursement Made in Excess or in Error
Effective
March 1, 2000, upon determination that the MCO reimbursed a provider in excess
or in error, the following steps shall be taken to recover the reimbursement:
The MCO
shall document the issues in memorandum form (or progress notes) to support the
recovery of reimbursement. The documentation shall include at a minimum the
following:
·
a summary of
the situation;
·
copy of
bill(s);
·
copy of bill
payment system screen(s);
·
individual
and group provider number(s);
·
document
number(s);
·
amount of
reimbursement in excess or in error;
·
time frame of
reimbursement(s) in excess or in error.
Within
seven (7) calendar days after determination that reimbursement was made in
excess or in error, the MCO shall notify the provider, in writing, indicating
that an overpayment has been identified. The provider notification letter
shall include at a minimum the following:
·
the policy
and/or rule violated;
·
the amount of
the overpayment;
·
evidence to
support the overpayment;
·
explanation
of the MCO’s grievance conference, indicating that the appeal period is 14
days;
·
steps the MCO
will take if (1) the health care provider agrees with the overpayment or (2)
the provider fails to respond;
·
the name and
telephone number of the MCO contact person to call if there are any questions.
If the
provider appeals the overpayment notice, the MCO has 10 business days upon
receipt of the appeal to resolve the issue. If the overpayment is upheld by
the MCO, the provider has 10 business days from notice by the MCO of the
resolution, to submit the overpayment to the MCO. The MCO has 10 business days
to submit the adjustment to BWC upon receipt of the money from the provider.
If the provider agrees with the overpayment or fails to respond to the provider
notification letter within the 14-calendar day appeal period, the letter will
serve as a full and final decision declaring an overpayment. The overpayment
is due and payable 10 business days after the appeal period has expired. If the
provider continues to perform
services that are reimbursable by the MCO, the MCO may recover funds from the
provider from any future reimbursements by indicating the overpayment in its
bill payment system or following other process the MCO has implemented.
If the
MCO determines that an adjustment is applicable to off-set future
reimbursements, the MCO identifying the error shall identify specific bills and
line items to be adjusted and submit with any supporting documentation. This
documentation shall be sent to BWC, Medical Billing and Adjustment Unit, within
seven- (7) business days after the provider’s appeal period has expired. BWC
will process the adjustment to recover reimbursements in excess, in
error
or overpaid by using the procedures already in place. It is the responsibility
of BWC to maintain documentation and to contact the MCO contact person who requested the adjustment if the
instructions are not clear.
NOTE:
The MCO contact person who requests
an adjustment must include her/his phone number. This will allow BWC to
contact the MCO contact person if
questions arise.
If the
provider remits a check to the MCO for the reimbursement made in excess or in
error, the MCO shall stamp the check with the receipt date (as defined in
Appendix G of the BWC/MCO contract) and request a bill adjustment in the same
manner as any other adjustment. The documentation shall be sent to BWC,
Medical Billing and Adjustment Unit, within seven (7) business days of receipt
of the check by the MCO. The MCO may deposit the check into its provider
payment account to offset the requested adjustment.
If the
provider either refuses to refund the overpayment or does not respond to the
overpayment notification, then the MCO shall send out a certified letter to the
provider requesting the refund. The letter shall include all details related
to the overpayment, including but not limited to claim numbers, dates of
service, overpayment amounts, etc.
If the
provider continues to refuse to refund the overpayment or does not respond to
the certified letter within 10 business days, then the MCO shall make phone
contact with the provider to discuss arrangements to obtain the refund. The
MCO shall make contact with the individual provider, office manager, the
provider’s legal representative or other designee of authority. The MCO shall
document the conversation in detail including, at a minimum, the name and title
of the person representing the provider, the date of the call, specific
discussion points and the provider’s detailed response.
If the
provider continues to refuse to refund the overpayment or does not respond to
the telephone conversation, then the MCO shall submit a packet of information
related to the overpayment to BWC MCO Audit Unit. The packet shall be sent to
BWC MCO Audit Unit within 10 business days of the refusal or lack of response.
The packet shall contain the following items:
·
Original
overpayment notification letter
·
Provider
appeal documents (if appeal was filed)
·
MCO decision
letter (if appeal was filed)
·
Certified
letter
·
Documentation
from telephone call with provider.
BWC MCO
Audit Unit will review the packet. If the packet is incomplete or if the
provider was not given adequate appeal rights, then the packet will be returned
to the MCO with further instructions. If the packet is complete, then BWC
Provider Relations will contact the provider or their designee and discuss the
overpayment. If the provider refuses to refund the overpayment or does not
respond to the telephone conversation, then BWC Provider Relations will refer
the issue to BWC’s Finance Department for collection.
Payment Errors Unrecoverable from Provider
Some payment errors are unique in that they are not the
result of any error by the provider and as such the provider rendered services
and sought reimbursement in good faith. In these situations the erroneous
payment will not be recovered from the provider. Payment errors unrecoverable
from provider are handled in two ways:
·
Payment errors resulting from substantial MCO error
·
Payment errors resulting from retroactive claim status or condition
allowance or hearing decision
Payment errors resulting from substantial MCO error
For the following guidelines, “responsible for payment”
means that BWC will recover funds from the MCO. In most of the “responsible for payment” cases, the MCO will not be allowed to recover
money from the provider, since the situations involve a substantial MCO error
Recovery
of Payments Made for Prior Authorized Services
The MCO
is responsible for payment and shall not recover from the provider for payments
for services that were approved, with a written prior authorization, and later
determined by the MCO, CST, MCO business unit or Provider Relations to have
been made in error. If the supply/service authorized in error has not been
provided the MCO shall immediately inform the provider verbally that the
service was authorized in error and will not be paid from this date of service
forward. If the supply/service has already been provided, the MCO shall
immediately inform the provider verbally that authorization was made in error
and the service/ supply will not be paid from this date of service forward. All
conversations shall be followed up in writing to the provider within five (5)
business days and copies of the letter shall be sent to all parties to the
claim (injured worker, employer, or his/her representatives) and the claim file.
The MCO
may be responsible for payments made in excess or error for services or
treatment to the injured worker as part of the medical management of the
claim. The MCO shall not recover reimbursement from the provider in the
following situations:
MCO
authorizes services after hearing order denies services.
The MCO
may be responsible for payments made for any services authorized by the MCO
after the denial, as determined by a
hearing, is documented in V3 Notes. The MCO shall not recover payments
from providers. There will not be an EDI 148 transmission from BWC to flag MCO.
The MCO has access to view notes in EDA and should review for date-sensitive
and services-specific information. The CSS will input into V3 notes and notify
MCO (by e-mail or phone) in accordance with Claims Policy –
MCO
authorizes services after hearing order disallows previously allowed claim.
The MCO
may be responsible for payment for services authorized by the MCO in a denied claim. In cases where
the claim was first allowed and then later denied by hearing, the MCO is
responsible for payment and shall not recover payment for services authorized
and rendered after the hearing is documented inV3. The MCO is notified via EDI
148 transmission after the hearing order disallows a previously allowed claim
and has access to view EDA. When the claim is disallowed, the claim status code
DA is sent in a REF segment. The claim status date is updated in a DTP segment.
The CSS will input into V3 notes and notify MCO (by e-mail or phone) in
accordance with Claims Policy – “Orders-Waivers-Appeals-Hearings”. No further
bills will be paid regardless of date of service.
MCO
authorizes services after hearing order disallows previously allowed
conditions.
The MCO
may be responsible for payment for services authorized by the MCO after a
hearing order disallows previously allowed conditions in the claim. In cases
where a condition was first allowed and then later denied by hearing, the MCO
is responsible for payment and shall not recover payment for services
authorized and rendered after the hearing is documented inV3. The MCO is
notified via EDI 148 transmission after the hearing order disallows previously
allowed conditions and has access to view EDA. The ICD-9 status is updated in
an III segment. The status date is updated in a DTP segment. The CSS will input
into V3 notes and notify MCO (by e-mail or phone) in accordance with Claims
Policy –
MCO
authorizes services after final settlement.
The MCO
may be responsible for payment for any services authorized by the MCO after the
final settlement date in V3 Notes. The MCO shall not recover payment from
providers. The MCO receives EDI 148 notification of final settlement and has
access to view via EDA.
MCO
authorizes out of statute of limitations.
The MCO
may be responsible for payment for any services authorized by the MCO after the
statute of limitations has expired. The MCO shall not recover reimbursement
from the provider for authorized services. The MCO is not currently notified
via EDI, however, the MCO has access to view EDA. The MCO needs to integrate
the BWC statutory time limits based on dates of injury, claim type and last
payment criteria into their medical management system.)
Inappropriate
use of EOB 776. (Provider Recovery may be appropriate)
The MCO may be responsible for payment for any services
authorized by the MCO for an unrelated or disallowed diagnosis using override
EOB 776. EOB 776 is intended for use when the MCO authorizes payment for
services for a condition that is non-allowed, but related to the allowed
condition(s) in the claim. Use of EOB 776 is prohibited when the condition
being treated is expressly denied in the claim. Indiscriminate use of EOB 776
will result in recovery and the MCO shall not recover said payment from
providers.
BWC
Recovery from MCO Process Flow
·
Possible
authorization/payment issue is identified by BWC.
·
Provider
Relations Dept. Unit is notified via e-mail (Lisa Landon/cc.Joyce Rodgers).
·
The Provider
Relations Dept. will gather the facts (medical and other justification for the
authorization and/or payment) from MCO, provider, claim file and notes from
CSS/V3.
·
Provider
Relations will review facts. If it is determined that the MCO made an error on
the authorization/payment, the MCO will be responsible for payment to provider
for services that were authorized and rendered.
·
Provider
Relations will notify MCO via e-mail of the BWC determination based on review
of facts. The appropriate MCO Business Unit representative will be copied on
the email. The email shall include at a minimum:
§
Claim number
§
Injured
workers’ name
§
Payee
provider number
§
Provider name
§
Date of
service
§
Amount billed
§
Invoice
number
§
Justification
for recovery of payment
·
MCOs may
appeal this determination to Provider Relations (email or fax 614-752-7946)
with supporting documentation within 14 days from date of email notification.
·
MCO appeal
will be considered by BWC committee consisting of members from Policy &
Support, Provider Relations and MCO Business Unit and, if appropriate, field
operations and Law. Provider Relations will disperse all information to the
committee members.
·
After review,
committee will make recommendations to Administrator’s Designee for final
decision within 14 days.
·
If MCO does
not appeal the decision, BWC will adjust bills paid in error to MCO after 14
days of notice. Provider Relations will complete hard copy adjustment forms
and attach copies of pertinent documentation. Adjustments will be sent to
Adjustment Unit for processing. Adjustment Unit will notify Provider Relations
when adjustment is complete.
·
Provider
Relations Dept will track and work with MCO to ensure payment resolution
Payment Errors Resulting From Retroactive Claim
Status/Condition Allowance/Hearing Decision
The MCO
is not responsible for payment and shall not recover from the provider payments
made in excess or error for services or treatment already reimbursed as part of
the medical management of the claim in the following situations:
Payment
was made for services/supplies ordered by hearing, then the hearing order is
later overturned and services are denied.
The MCO
shall not recover payments from the provider for payments made for services or
supplies prior to the last hearing order. The MCO is not responsible for bills
for date(s) of service prior to the last hearing order. Payments are to be
adjusted and will be charged to surplus. The CSS will input into V3 notes and
notify MCO (by e-mail or phone) in accordance with Claims Policy –The MCO has access to view notes
in EDA and Dolphin..
Payment
was made for services/supplies in an allowed claim that later, due to a hearing
order, becomes a disallowed claim.
The MCO
shall not recover payments from the provider for payments made for services or
supplies prior to the last hearing order. The MCO is not responsible for bills
for date(s) of service prior to the last hearing order. Payments are to be
adjusted and will be charged to surplus. The CSS will input into V3 notes and
notify MCO (by e-mail or phone) in accordance with Claims Policy – “Orders-Waivers-Appeals-Hearings”.
The MCO has access to view notes in EDA and
Dolphin.
Payment
was made for services/supplies for a condition that later, due to a hearing,
becomes a disallowed condition.
The MCO
shall not recover payments from the provider for payments made for services or
supplies for a condition prior to the last hearing order. The MCO is not
responsible for bills for date(s) of service prior to the last hearing order.
Payments are to be adjusted and will be charged to surplus. The CSS will input
into V3 notes and notify MCO (by e-mail or phone) in accordance with Claims
Policy – “Orders-Waivers-Appeals-Hearings”. The MCO has access to view notes
in EDA and Dolphin..