Ohio, New York and Minnesota Show How Fast Medicaid Payments Can Stop
Ohio's proposed Medicaid suspension rule, New York's prepayment review order and Minnesota's clawback warning show how payments can stop before any finding.
Three states moved on Medicaid payments in two weeks
A week after HHS gave CMS its own authority to exclude providers, CMS officials held a briefing on New York's Social Adult Day Care program. They said some centers will be excluded and that the state has 30 days to respond and 90 days to come into compliance. The day before, Governor Hochul directed the state's 35 Managed Long Term Care plans to put adult day care claims on prepayment review and pursue payment suspensions.
In Ohio, the Department of Medicaid has proposed new rules on suspending provider agreements, with a public hearing on November 16. In Minnesota, the Department of Human Services told Becker's it may have to claw back money from providers if CMS disallows the $550 million in federal Medicaid funds it has deferred this year.
In none of these cases does anyone have to be convicted first. Payment stops first. A finding, if there ever is one, comes later.
Ohio's proposed Medicaid suspension rule
Under proposed OAC 5160-1-17.5, the state must suspend a provider agreement and withhold payment when there is a credible allegation of fraud or a disqualifying indictment against the provider or any of its owners, officers, agents, managers or employees. Payment is withheld regardless of date of service, and the suspension can extend to every other Ohio Medicaid agreement the provider holds.
If you run several locations or programs under common ownership, that language applies to you. An indictment against one employee at one site can stop payment at all of them, and you get 30 days to ask for reconsideration with no appeal of the final decision.
How a Medicaid payment suspension hits cash flow
A suspension stops payment on claims you've already submitted. Prepayment review is slower but just as bad: your clean claims sit there while someone pulls records, and nothing posts until they're done. A clawback is the worst of the three because that money was already in your account months ago. For a practice where Medicaid is a third of collections, a 90-day hold is a full month of revenue gone.
States have gone after adult day, home and community-based services and behavioral health first, so that's where the risk is highest right now. But the Ohio rule reaches a provider through its owners and staff, not its service line, so this isn't only an adult day problem.
What to check if you bill Medicaid
Pull your Medicaid enrollment records and look at who is listed as an owner, officer or managing employee. If someone left two years ago and is still on there, fix it, since an allegation against that person can reach the whole organization.
Screen the same people against the OIG and state exclusion lists every month and keep the results somewhere you can find them. Pick the person who answers a records request before you get one; in Ohio you have 30 days. If you bill Ohio Medicaid, read the proposed rules yourself and consider commenting at or before the November 16 hearing.
Discuss this post on LinkedIn
Questions, or a different read? Join the conversation where Tony posted it.
About the author
Tony Kuka · Founder, Ziurta
Tony is the founder of Ziurta, a provider enrollment platform for medical practices, health systems, RCM firms, and credentialing companies. He has 30 years in healthcare administration, including 20 building outsourced revenue cycle companies, and founded and sold Medical Business Office and National Credentialing Solutions. He is based in Chattanooga, Tennessee.