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OhioBWC - Basics: (Policy library) - File

InfoStation Document

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..

 

 


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