Palmetto Recoupment One-Month Filing Extension of "Improperly" Paid Claims

Bill Finerfrock, Executive Director


Palmetto Recoupment One-Month Filing Extension of “Improperly” Paid Claims

Yesterday (7/10) I expressed my disappointment that the most recent posting by Palmetto regarding challenges to the recoupment notices did not reflect an understanding we had reached with CMS last week. Specifically, that RHCs would have until mid-August to file reconsideration notices for recoupments they felt were in error.

I communicated to CMS officials our disappointment with the posting and that it did not reflect what CMS said they would do.

Yesterday afternoon, I received an updated posting modifying the July 6th Palmetto posting that reflects what CMS said during our meeting on July 5th. This is the new posting:

07/10/2018: Postponement of Claim Cancellation/Recoupment: Providers who have exceptions they feel are warranted must at least start the exception process by submitting an INITIAL exception request no later than close of business on August 17, 2018. Receipt of an INITIAL exception request – with documentation – will result in a postponement of recoupment of ALL claims for which recoupment is sought until a determination is made of the legitimacy of the challenged claims. Even if you are unable to complete your review of ALL claims prior to July 16, recoupment will be stopped for ALL claims upon receipt of a valid INITIAL exception request. Palmetto GBA will begin the auto-cancellation of affected claims for providers who did not submit a valid INITIAL exception request on August 18, 2018.

This one-month extension (August 17th) of the date for filing an INITIAL exception request is consistent with what we discussed with CMS. I want to thank CMS leadership for providing this additional time for RHCs to review the claims for which recoupment is being sought.

What NARHC is continuing to do:

NARHC continues to push CMS to direct the Medicare Advantage Plans to waive their timely filing requirements so that any claims that were paid by traditional Medicare but were actually the responsibility of the MA plan, can be submitted to the MA plan for processing and payment.

We’ve not received any recent updates on this and will pass along any information we receive as soon as it is available.

It has been estimated that the total amount in question – when you combine all of the provider-types affected (RHCs, hospitals, CAHS, SNFs and ESRD facilities) – is close to $60 Million.

If the MA plans are not required to waive timely filing and accept, process and pay these claims, this means that the MA Plans will have retained $60 Million in profits from money that should have gone to health care providers for medically necessary care the providers delivered to Medicare beneficiaries. All due to an error by a Medicare contractor.

NARHC will continue to push CMS on this important point.

What you can/should do over the next 30 days?

If you have received a recoupment request, it is in your best interest to review ALL claims for which recoupment is being sought. NARHC is receiving reports from many RHCs that claims Palmetto is alleging were improperly paid had previously been identified by the RHC and any monies improperly paid for those claims had already been repaid to Medicare.

Submit a request for reconsideration as soon as you identify an error. You do not need to submit all challenges at the same time. You do not need to complete your review before submitting any challenges. However, you will have to provide some evidence to support your challenge.

By submitting a request for review – including the information you have supporting your challenge – Palmetto will suspend any recoupment efforts for your clinic until ALL claims/beneficiaries for whom review has been requested have been resolved.

Finally, let me know at how this process is going.

NARHC will continue to provide additional updates as information warrants.

Please do not hesitate to contact me if you have any questions.

Bill Finerfrock