The CareSource building located at First and Jefferson Streets in Dayton.
Dayton-based health insurer CareSource is reversing a previous decision to seek repayments from behavioral health providers that it has overpaid for about the past two years for services for CareSource members.
In late April, certain behavioral and mental healthcare providers in Ohio received notices from CareSource that it had found an error in how it had calculated reimbursements paid to the providers. CareSource had planned to seek repayment from those providers for the full two years, first giving the providers a bill for two months of overpayment.
After receiving pushback from providers and learning how this could impact its members, CareSource announced it will not be seeking the recoupments , but will still go forward with the correct rate reimbursements in the future.
“Earlier this month we notified some behavioral health providers in our network that CareSource had inadvertently overpaid them and would be implementing the correct rates consistent with the terms of their contracts, both retrospectively and for future claims. Individual providers impacted by this change will be notified. This action did not represent a rate reduction,” a statement from CareSource reads.
Behavioral and mental healthcare providers who recently spoke with the Dayton Daily News said that if CareSource sought repayment for the full two years, it could have potentially closed their doors or led them to not being able to accept CareSource insurance in the future.
“After direct conversations with providers over the past several days, CareSource has decided to suspend the recoupment of those overpayments. The providers we spoke to shared that the recoupment would create significant financial strain and could impact access to care for members. That feedback directly informed our decision,” CareSource’s statement said.
The overpayment was discovered during a review of past payments CareSource had made to behavioral health providers.
Beginning in 2024, reimbursement rates for physicians providing behavioral health services were set at 100% of the Medicaid maximum rate, while they are 85% for non-physicians, like clinical nurse specialists, certified nurse practitioners, and physician assistants, according to the Ohio administrative code.
CareSource had been paying all behavioral health providers, not just physicians, the 100% of the Medicaid maximum rate when the health insurer said it should have been reimbursing the non-physician providers at 85%.
“Future claims will be paid at the correct rate based on the terms of our provider agreements, which apply rates in specific circumstances based on service, provider type and clinical setting. Applicable behavioral services rendered by a licensed or supervised practitioner are reimbursed at 85% of the established Medicaid fee schedule in most cases,” CareSource’s statement said.
“As behavioral health costs continue to rise, CareSource is committed to working with Ohio’s healthcare community to advance a high-quality and sustainable behavioral healthcare system. We look forward to collaborating with the state, providers and other health care partners to ensure access to critical services for Ohioans.”
Other routine recoupments not related to this instance of overpayment will still be taking place. In Ohio, health insurers currently have two years to recoupment overpayments from providers, but Senate Bill 162 — a bill that was just recently passed in the Ohio Senate and has moved on to the Ohio House — would reduce that time frame down to one year.
CareSource administers one of the largest Medicaid managed care plans in the U.S., offering health insurance — including Medicaid, Health Insurance Marketplace and Medicare products — to more than two million members across 12 states. Across the CareSource brands, the company saw more than $13 billion in revenue in 2024, according to nonprofit tax filings, with earnings exceeding $386 million.