NCMS Urges Guidance from Medicaid on December Recoupment

Anticipates Good Result on Denied TPL Claims

As 2015 was winding down, physicians were hit with an unpleasant surprise by North Carolina Medicaid – an unannounced reprocessing effort involving approximately 292,000 claims. The official reason for the reprocessing was to apply a 3 percent rate reduction that should have been in effect when the claims were originally processed, but was not.

To make matters worse, many practices reported that some reprocessed claims were denied outright for other reasons such as “third party liability or TPL” and for violating NCCI edits. The recoupment amount on those was 100 percent, not just 3 percent.

Upon learning these details, North Carolina Medical Society (NCMS) staff met immediately with senior Medicaid officials for an explanation as to why the 3 percent recoupment was so late, why so many claims completely denied, and what options remained for pursuing reimbursement on these already-rendered services.

In short, Medicaid acknowledged the lack of adequate communication and pledged to send a more complete explanation. After several weeks, NCMS expects Medicaid will release a Frequently Asked Questions document regarding the December recoupment in the next couple days. Please watch for this important communication if you were affected by the December recoupment.

We further anticipate the FAQ will include some good news: Medicaid plans to automatically reprocess all claims that denied for “third party liability or TPL” and repay at the corrected rate (assuming the claim is otherwise “clean”). Approximately 47,000 claims fall into this category.

 

 
 

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