Medlearn Media NPOS Non-patient outcome spending

Double-dipping has been seen among some Managed Care Organizations.

How many readers have undergone more than one audit? What about more than one audit for the same years or dates of service (DOS)?

Recently, I noticed that some auditors are doing what I would call “double dipping.” They are attempting to recoup monies twice for the same date of service for the same procedure and consumer.

Obviously, this is not allowed and it is easily defendable. But what if you never notice? This occurs especially with extrapolated audits. The universe of audited claims can be so large and encompass so many DOS that a provider may not catch the overlap. Plus, the audits may be from two different companies. Your attorneys or your statistical expert whom you hire to debunk the extrapolation can check for overlap as well.

Next, I want to discuss managed care organizations (MCO), which have become prevalent is about 40 states now. Capitated managed care is the dominant way in which states deliver services to Medicaid enrollees. These MCOs are generally private companies tasked to manage Medicaid dollars for their state. Supervision of their actions is limited or barren. Even though these MCOs may have their own contracts with providers, those contracts cannot circumvent federal law. Now when you sign these MCO contracts, you have no bargaining power.

While the federal regulations dictate that you should have all the appeal rights for adverse decisions that your state offers, many times these MCO contracts include arbitration clauses. An arbitration clause removes you from the appeal process owed to you and forces you to arbitrate, which is a much more expensive litigation route.

More and more, I am first fighting the arbitration clause in the contract just to follow the normal appeal process of whatever state we are in. Each state has an administrative law process, procedure, and administrative courts with judges. The administrative courts are the courts to “police” state agencies, including each state’s Medicaid agency, including the MCOs contracted with the state agency. The correct venue for provider Medicaid appeals is in administrative court, not arbitration.

The same is true for Medicare provider appeals; there is an administrative process for appeals. So why are these MCOs and MACs adding in arbitration clauses? While I do not know the reason for doing so, I can tell you that arbitration clauses cause the provider to pay more in litigation if they decide to arbitrate or fight the arbitration clause. It puts providers in between a rock and a hard place.

Check your contracts.

Programming note: Listen to healthcare attorney Knicole Emanuel’s RAC Report every Monday on Monitor Mondays, 10 Eastern.

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