Update on Palmetto Recoupment of "Improperly" Paid Cliams

Bill Finerfrock, Executive Director


Update on Palmetto Recoupment of “Improperly” Paid Claims

Last week I had a meeting with senior leaders at CMS to discuss the efforts by Palmetto to recoup monies they believe were improperly paid by Cahaba for Medicare beneficiaries enrolled in MA plans at the time the services were rendered. When that call ended, I believed we had an agreement to provide additional time to RHCs to review the information provided by Palmetto to determine the accuracy of the claims denials. Specifically, I believe we had an agreement to give RHCs until mid-August to review and submit challenges and that recoupment would be delayed until that time. Late yesterday I was given an update – put out by Palmetto – that does NOT reflect the agreement I felt had been reached between NARHC and CMS. I have already expressed my concern about the difference between what has been posted and what I felt we’d agreed to with CMS.

The following appears on the Palmetto website:

Status as of 7/6/2018: 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 July 16, 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.

Here are the links to review what is posted on the Palmetto website on this issue. I will say, however, that I find the information confusing and contradictory.

CLICK HERE for Link #1
CLICK HERE for Link #2
As noted, it was my understanding from my call with CMS that RHCs would be provided additional time to review the claims/beneficiaries in question and have until mid-August to submit their challenges. The above message states that requests for review must still be submitted by Monday (July 16) and only recoupment itself will be delayed until August 18th.

What you can/should do?

First, if you received a recoupment notice from Palmetto and you believe that it has errors, you MUST submit a request for reconsideration as outlined in the above postings. You do not need to submit all challenges at the same time. You do not need to complete your review before submitting any challenges.

Second, As you find additional errors, submit those as well. 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 bf@narhc.org how this process is going.

What NARHC is doing?

I believe I made it clear that RHCs needed more time to properly review the individual situations where there might be potential questions about the validity of the Palmetto recoupment order. The Palmetto update does NOT provide any additional time for the review, it merely delays the date upon which recoupment will commence.

In addition, we also discussed the issue of timely filing of claims where there was agreement that the individual was enrolled in an MA Plan and that the MA Plans, not traditional Medicare, was responsible for paying the claims. CMS agreed to work with the plans to get timely filing waived.

If timely filing limits are not waived and Medicare successfully recoups these monies, the financial ramifications for RHCs and others (hospitals, CAHS, SNFs and ESRD Facilities) will be devastating. It is highly likely that many facilities will have to seek bankruptcy protection and in the most extreme cases, close their doors leaving entire communities with no healthcare providers.

To me, the greatest irony is that if timely filing is not waived, the MA Plans will be allowed to retain millions of dollars in revenue (i.e. profits) that rightfully should have been paid to RHCs, Hospitals, CAHs, SNFs and ESRD facilities for medically necessary care delivered to Medicare patients.

I will provide additional updates as information warrants. Please do not hesitate to contact me if you have any questions.

Bill Finerfrock