September 11, 2018
Area(s) of Interest: Payor Issues and Reimbursement Practice Management Public Payors
The California Medical Association (CMA) has learned that L.A. Care Health Plan, the publicly operated Medi-Cal health plan serving more than 2 million Los Angeles County residents, issued letters to physicians in late July requesting the refund of claim overpayments dating back to 2012. The letters, dated July 28 and received by practices through mid-August, cited that the overpayments were a result of processing errors, including the following:
- L.A. Care incorrectly processed Medi-Medi claims as the primary payor instead of secondary to Medicare.
- L.A. Care mistakenly paid the Medicare copay, coinsurance and/or deductible even though the primary insurer’s reimbursement for the claim had already exceeded the maximum allowable Medi-Cal amount. (Total maximum Medi-Cal allowable amount is composed of both Medicare and Medicaid payments in these scenarios.)
CMA has raised concerns with L.A. Care about the timeliness of some of the refund requests. California law allows Knox-Keene plans 365 days from the date of payment in which to request a refund, except in cases of fraud or misrepresentation (28 C.C.R. §1300.71(b)(5). Many of the L.A. Care refund requests are beyond that statutory timeframe.
Physicians who received refund requests beyond the 365-day timeframe from the date of payment are encouraged to submit a formal written dispute to L.A. Care to the address listed on the recoupment letter:
L.A. Care Health Plan
P.O. Box 811610
Los Angeles, CA 90081
Fax (213) 438-5057
It’s important to note that the “Improper Payment Findings” attachment to the overpayment letter asks physicians to sign and date if they agree to have the overpayments deducted from future services and return to L.A. Care. Physicians are not required to sign the document and should carefully consider whether they wish to dispute any of the overpayment requests, or whether they agree to have all of the requested overpayments withheld from future payments.
California law requires practices that wish to dispute overpayments to submit within 30 working days of receipt of the notice from the payor. Failure to do so may result in an automatic withhold of monies against current claim payments by L.A. Care.
While the overpayment notices were dated in late July, many practices reported to CMA they did not receive the notices until late August. At the request of CMA, L.A. Care has agreed to extend the appeal timeframe to September 28 for physicians affected by the refund requests.
Physicians with questions can contact the CMA reimbursement helpline, (888) 401-5911 or firstname.lastname@example.org.