Caresource recouping behavioral health overpayments
The largest managed care organization of Medicaid in Ohio has confirmed to 21 News it will be clawing back 15% of the reimbursements it made to some behavioral health providers over the past two years.
“We understand this may cause concern for some providers, and we are committed to working with them to review their individual circumstances,” a spokesperson for CareSource wrote in a statement. “Throughout this process, we remain focused on protecting our members’ access to quality care and supporting provider network stability.”
Not all behavioral healthcare providers are legally supposed to be reimbursed the same amounts by Medicaid managed care organizations.
Those who are accredited by the Ohio Department of Mental Health and Addiction Services (OMHAS) as an official Community Behavioral Health Center receive 100% reimbursements. These providers are also known as Medicaid Provider Types 84 and 95.
Under the Ohio Administrative Code, those without that OMHAS accreditation are to be reimbursed 85% instead of the full amount. The agreement that managed care organizations like CareSource have with the Ohio Department of Medicaid (ODM) allows them to recoup overpayments made to providers within two years.
CareSource statement
“This is not a rate reduction, but rather an effort to ensure CareSource is accurately paying claims in accordance with our fiduciary duty as a steward of public funds.”
CareSource spokesperson
This is the step CareSource is now taking, after finding that it “historically” paid the full amount to those who were only meant to be reimbursed 85%. A statement from a CareSource spokesperson said the mistake was caught during a routine claims review.
Going forward, the reimbursement rate will be fixed to the correct 85%, which for many behavioral health providers will feel like a rate drop.
“CareSource’s mission is to improve the health and well-being of Ohioans,” the statement read. “As part of this commitment, we responsibly manage Medicaid funds to maintain high-quality, affordable care. … This is not a rate reduction, but rather an effort to ensure CareSource is accurately paying claims in accordance with our fiduciary duty as a steward of public funds.”
The Ohio Council of Behavioral Health & Family Services Providers wrote in a Thursday message to its members — shared with 21 News — that the council “will continue to monitor this issue closely and provide updates” and guidance as relevant.
Some mental health professionals have sounded the alarm that the clawbacks could lead providers to close or drop CareSource, jeopardizing essential care for Medicaid patients. Mary Hall, president of MGH Healthcare in Howland, told 21 News she is not as worried.
“My understanding is that CareSource is going to work with the providers to be able to pay back that money over time, and hopefully keep those practices going,” Hall said in an interview Friday.
“It’s always difficult to pay back money that you’ve already received,” she later added. “However, really if someone’s managing their practice well, they should have been able to pick up on that error that they were being paid too much.”
Many other mental and behavioral health care providers contacted by 21 News did not respond to our requests for information on how the move could impact their services.