Supervisor Do calls on Medi-Cal to stop taking money back from CalOptima doctors

For Immediate Release: June 11, 2015

Contact: Brian Probolsky, (949) 533-4254

OC SUPERVISOR ANDREW DO CALLS ON MEDI-CAL TO HALT CLAWBACK OF MILLIONS OF DOLLARS FROM CALOPTIMA DOCTORS

(Santa Ana, California) – Years after the bills have been paid, the state’s public health insurance program has begun to demand repayment of millions of dollars from doctors who provide health care to low-income families, children, seniors and persons with disabilities in Orange County.

Orange County Supervisor Andrew Do, a member of the CalOptima board of directors, is calling for an end to this clawback by the state’s fee-for-service Medi-Cal program, arguing that the process is unfair and could result in more doctors leaving CalOptima, Orange County’s low-income health insurance program.

“Medi-Cal made the mistake, yet it’s shifted the costs to doctors and patients,” said Supervisor Do, who discovered the problem after receiving complaints from Orange County ophthalmologists. “It’s wrong for Medi-Cal to unilaterally withhold payments on new claims as it tries to clear up old billing disputes.”

Between July 26, 2011 and May 21, 2013, claims for services provided to dual-eligible patients – those enrolled in both Medi-Cal and Medicare – sent by Medicare to the state fee-for-service Medi-Cal program were erroneously paid by the state’s fiscal intermediary, Xerox, rather than rejected. Such rejections would have triggered doctors to bill Orange County’s own public health insurance program.

Now, Medi-Cal is recouping the improper payments from current billing claims submitted by doctors and issuing demand letters for amounts that range in the tens of thousands of dollars if the recoupment is not occurring quickly enough. In some cases, Medi-Cal appears to be charging interest on the money owed.

Adding to the confusion and frustration: uncertainty over whether the doctors can legally go back to claim the mis-processed payments from CalOptima due to the significant passage of time.

“This was clearly and admittedly a mistake made by Medi-Cal, yet it is placing these providers in a position to possibly suffer financial hardship,” said Dr. Craig H. Kliger, executive vice president of the California Academy of Eye Physicians and Surgeons. “That is exactly the wrong message for the State to be sending to providers who are willing serve this vulnerable population.”

At last Thursday’s CalOptima Board of Directors meeting, Do called on CalOptima staff to investigate the issue and identify how CalOptima can assist doctors in resolving the billing dispute.

Until affected health care agencies have a full understanding of the problem, he’s calling for Medi-Cal to:

1) Immediately halt the clawback of funds;
2) Continue to pay doctors for undisputed claims; and
3) Work with doctors to reach a fair compromise on the billing dispute.

An estimated 1.1 million low-income seniors and people with disabilities receive health care services through both the Medicare and Medi-Cal, according to the state Department of Health Care Services. It’s unclear whether other counties throughout the state are also affected by the problem.

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Orange County Supervisor Andrew Do represents the First District, which includes the communities of Garden Grove, Santa Ana, Westminster, Fountain Valley and Midway City.