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Court Finds DCH’s Handling of Mass Reprocessing “Inconsistent and Misleading”

DCHIn a decision last week, the Office of State Administrative Hearings (OSAH) reversed the Department of Community Health’s (DCH) denial of a Request for Administrative Review by a group of Children Intervention Services (“CIS”) providers. The CIS providers had requested a review of recoupment actions that stemmed from two 2014 Mass Reprocessings by the Department, one involving NCCI edits that included claims dating back to 2010.  The Department argued that the providers missed the 30 day deadline to file a Request for Administrative Review.

Attorney Kimberly Sheridan of Jeyaram & Associates represented the group of CIS providers in the administrative hearing and argued that the providers should be granted a review because they followed all the instructions specific to the mass reprocessing posted by the Department in several banner messages and emails, as well as in-person conversations. Through the banner and email message instructions, the Department departed from its standard deadlines in its policy manuals.  The Court found that the Department’s position was “illogical and wholly unfair,” and that its instructions to the providers after the mass reprocessing were “inconsistent and misleading.” The Court also said the providers had justifiably relied on these instructions and could not now be penalized for their reliance.

At this time, the Department has not made it known if it will appeal the decision.

If you are a provider subject to a recoupment and need help, or if you need to appeal DCH’s decisions, Jeyaram & Associates has extensive experience and success with these cases. Contact Kimberly Sheridan at ksheridan@Jeylaw.com or 678.325.3872.

CIS Recoupments Begin – Still Time To Appeal

CIS Recoupment ClaimsThe first Special Remittance Advices (“RA”) pursuant to the Department of Community Health’s CIS Claims Reprocessing were issued this week.  Claims originally processed between November 1, 2010, through June 30, 2012, that billed specific CPT codes are subject to this special reprocessing based on the CMS National Correct Coding Initiative mandated by the Affordable Care Act.

Early reports are that the Special RA’s detailing the voided claims have been several hundred pages long with recoupments reported from $5000 to $100,000.

Some providers have indicated that DCH may be willing to enter into payment plans with providers to space-out the recoupment amount and that the Department may also allow denied claims to be re-billed with the proper CPT modifiers to allow for payment.

Section 202 of DCH’s Part I:  Policies and Procedures Manual requires that claims be received within six (6) months after the month in which service was rendered to be reimbursed unless certain exceptions are met.  It is unclear whether DCH considers the Special Reprocessing as meeting the exception requirements.  If it does not, then providers may be limited to six (6) months for re-billing claims.

If you think the Department’s determination of recoupment is incorrect, you can still appeal the determination as described in Part I of this article. It is extremely important that you satisfy all of the appeal requirements and meet all deadlines.  Failing to do so means that you waive your appeal rights and may not be able to challenge the DCH action.

If you’ve received notice that your practice is subject to the reprocessing recoupment and need help or if you need to appeal DCH’s decisions, Jeyaram & Associates can help. Contact DJ Jeyaram at DJ@Jeylaw.com or 678.325.3872.