I want to bring some awareness to the subject of recoupment by MCO’s. I an currently being asked to pay back a few thousand dollars. My understanding is that an MCO was audited and found 39 claims that were paid in error. Now, we are all human and make mistakes, but 39 times without someone catching the error, c’mon? The problem is that it was not an error. The audit declared that the CPT code that was billed was incorrectly. At the time of filing it was not incorrect according to the MCO. Fast forward 5 years and I am now being asked to pay the money back. My contention is that there needs to be a statute of limitations on recoupment. With this particulary MCO, I have only 4 months to file a claim. However, there is no statute on recoupment whether it be 1 year or 40 years. Just wondering if anyone else is experiencing a similar problem. I support enacting legislation that would place a statute of limitations of 6 months from the time of payment on recoupment by any MCO. Think about it … all the money you have ever earned from an MCO is never really yours if they decide to take it back without such a law in place. This problem obviously transcends just the counseling profession. I have spoken with an attorney who suffered a similar fate on a personal injury case. They distributed funds to the client, and then insurance recouped the money at a much later date. Quite simply, we need a law in place that let’s us know if/when the money we receive is actually ours. I could see there being significant support across all health fields that work under contract with MCO’s.
Recoupment of money by MCO
by Paul Guys | Aug 2, 2021 | Members Forum | 7 comments
I 100% agree. This is one of the reasons therapists stop taking insurance, limiting clients’ access to affordable care, but out of a need to survive as a provider financially. If there is a term limit for us as providers to file a claim, there should be a term limit for companies to be allowed to do this. If none of the money we ever make is ours…that is outrageous and absolutely terrifying, as–if there is no time limit or limit to the amount–this could end a practice, especially a private practice. I have had this happen a few times and thankfully never so much it gutted me financially, but it is disturbing to know that none of my income I and my family rely upon is ever safe if paid by an MCO. There really should be a law in place that holds MCO’s accountable to a time limit to admit to find and recoup errors.
Wow what CPT code was it?
I agree as well. There won’t pay claims if submitted beyond 60-90 days. The same should apply that they can’t recoup money after that time!
CPT code 90847 was originally filed. It was basically a mother with 3 children. Each child was seen individually with mother present in a primary care clinic setting. Each child had individual behavioral health issues and received medication management within the clinic. MCO is now saying that only 1 child per household could be billed per day because I was providing “group family therapy.” I thought CPT code 90853 was for group family therapy. Besides, these children were not seen at the same time. None the less, in order to get paid, I am having to rebill as CPT code 90832 for 30 minute individual psychotherapy.
Here is my comment; you bring some valid points. Is it best to go through a billing agency that can perform the billing for my outpatient mental health agency? I am seriously considering taking the citification training if there is a process for billing and coding.
I took training with TLPCA recently and have yet to see any certificate that I did the training.
Thank you all so much for adding to this subject. I had no idea. What can we do to help change this procedure or is it part of the beast that at some level makes sense to the big companies to avoid being taken advantage of?