State Health Plan to Seek Reimbursements from Ineligible Members, Not Physicians

Last fall, the NCMS learned that State Health Plan (SHP) officials were considering directing its Administrator, BlueCross BlueShield of North Carolina, to recoup payments from physician practices for medical services provided to thousands of newly-discovered ineligible SHP members.  NCMS immediately contacted the SHP to explain that physicians were blameless parties in these transactions, that a massive recoupment effort would be stridently opposed by the physician community, and to urge Plan officials to consider alternate strategies.  Physicians should not be penalized when a health plan is unable to accurately identify its own participants.

On Wednesday the SHP notified NCMS that it would not attempt to recoup payments from physicians, and would instead seek repayment directly from those members who were not properly enrolled in the Plan but represented otherwise to their doctors.

This is the latest development involving the SHP’s comprehensive Dependent Eligibility Verification (DEV) project that began last year.  The verification process, an effort to control costs for Plan members and taxpayers, revealed thousands of members – mostly dependents – who did not meet enrollment criteria but were nonetheless receiving medical services through the SHP.

 
 

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