Providers Not Liable for Medicaid Overpayments Due to Missing Docs

Suppliers will not be chargeable for Medicaid overpayments based mostly on imperfect or lacking documentation alone in response to the Supreme Court docket of Wisconsin in Papa and Skilled Homecare Suppliers, Inc. v. the Wisconsin Division of Well being Companies, 2020 WI 66, — Wis. second —, — N.W.second — (Papa). Within the Papa case, Medicaid suppliers argued that the Wisconsin Medicaid Company had repeatedly tried to implement a coverage that medical information have to be excellent to ensure that suppliers to retain fee for providers furnished to Wisconsin Medicaid Beneficiaries. When auditors discovered imperfections in suppliers’ information, Wisconsin Medicaid would recoup funds beforehand made for Medicaid providers.

The Papa court docket rightly famous that Wisconsin Medicaid is required to abide by guidelines and rules imposed by the federal authorities in return for federal funding for well being care providers.

“The State of Wisconsin has joined the federal Medicaid system, and has consequently dedicated itself to following the federal legislation governing that system.”

-Id., at ¶ 4 (inner quotations omitted)

Whereas Wisconsin Medicaid is required to audit Medicaid suppliers, and to recoup overpayments; the principles relied upon to recoup funds made to Medicaid suppliers didn’t assist a requirement for excellent recordkeeping.

“The distinction between imperfect information and no information in any respect is a big one.”

-Id., at ¶ 38

Examples of imperfect information that didn’t create an overpayment or in any other case assist recoupment from suppliers in Wisconsin included:

Failure to counter-sign orders,

Failure to invoice different payors previous to billing Medicaid for Medicaid coated providers, and

Lacking components of a file when coated providers have been in any other case demonstrably furnished.

Medical information needn’t be excellent for suppliers to be paid and retain reimbursement for providers furnished to Wisconsin Medicaid beneficiaries. Recoupment of Medicaid funds ought to happen provided that the Medicaid program can’t confirm from the supplier’s information {that a} service was really offered or the quantity claimed (or paid) was inaccurate or inappropriate. Although the Papa case solely immediately applies to Wisconsin Medicaid, suppliers throughout the nation going through an overpayment demand or recoupment ought to rigorously evaluate the claims at problem to find out if an enchantment may very well be profitable.