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Date: April 14, 2014
To: Participating Primary Care Physicians (PCPs)
Re: Recoupment of Some Enhanced
Payments Made to PCPs under Affordable Care Act
(ACA)
Many Primary Care Physicians (PCPs) in the specialties of Internal
Medicine, Family Medicine and
Pediatrics have received enhanced payments for several
services they have provided to Medicaid
patients since January 1, 2013
following their required attestation. These additional
payments over and above the Medicaid Fee Schedule, provided with 100% funding by the Federal Centers for Medicare and Medicaid Services (CMS), were prescribed by the Affordable Care Act
(ACA)
for 2 years and are slated to expire December
31, 2014. This department has acted as an intermediary for collection of those funds from the CMS and distribution for qualifying PCP services in accordance with the federal guidance.
The purpose of this notice is to inform participating Primary Care Physicians that
the
federal guidance,
now clarified, limits additional payments for specified services only to those patients who receive Medicaid benefits under Title
XIX. A smaller number of patients on Title XXI
and some state
funded programs are not
eligible for enhanced payments under the ACA. Those additional
payments
made
in error on claims received between January 1, 2013 and November
17, 2013 (the date that error
was
corrected) to patients in Title XXI
and state funded programs will therefore need to be
recouped according to federal
rules. That take-back, although inconvenient and an unfortunate necessity, will only affect 3%-4% of the total
enhanced payments made under the program and will be
applied only on future vouchers for enhanced ACA payments, until
recouped. The department will
not recoup against any other type of payment.
On March 10, 2014,
the
department began issuing remittance advices identifying the erroneous
payments with an Adjustment
Reason Code 3317, (ACA Pmt Recoup/Client Category Ineligible).
Unfortunately, there is no such reliable system
currently available which will allow the participating
PCPs to definitively determine in advance whether a patient about
to
be seen or billed is Title XIX, Title XXI, or State-Funded. However, the participating PCPs will continue to receive enhanced payments for qualified services to a
vast majority of patients they see.
Any
questions regarding this notice may be directed to a medical assistance consultant in the Bureau of Professional
and Ancillary Services (BPAS) at 1-877-782-5565.
