DAYTON — One of Dayton’s largest employers is pausing surprise bills that demanded thousands of dollars.
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As reported on News Center 7 at 6:00, our I-Team has been following Medicaid payments that CareSource said it should not have paid mental health providers across Ohio.
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On April 24, the company wanted the money back. This afternoon, I-Team Lead Investigator John Bedell learned it is changing course.
>> PREVIOUS COVERAGE: Mental health provider shares concerns on CareSource Medicaid payment clawbacks
CareSource previously told the I-Team that these claw-backs were part of its “fiduciary duty” as a steward of public money.
But providers were worried about the financial strain this would cause.
Just before a scheduled protest in front of the CareSource Headquarters in Dayton, the I-Team learned that demand letters will stop showing up.
Friday afternoon, the I-Team saw providers protesting.
“No more cuts, no more greed, give us what providers need,” they said.
The I-Team has been following Carla Urbanas’ story.
She’s been a mental health counselor for 30 years.
She told the I-Team that about 10% of her clients in Vandalia and Centerville have Medicaid insurance through CareSource.
“After we see a client for a session, we have our billing company, and they bill CareSource electronically, and then we get reimbursed for that session,” Urbanas said.
That represents half of Holly St. Pierre’s clients at her practice’s offices in Kettering, Englewood, and Lebanon.
“We treat a population of vulnerable populations,” St. Pierre said.
Last week, both therapists got the first round of payback demand letters from CareSource.
St. Pierre was worried about what would happen to her so-far $12 bill if the letters kept coming.
“If we make a projected estimate, it’ll be close to $25,000,” she said.
St. Pierre said if she had to pay it, it would put her under, and she would have to close her doors.
Just hours before their protest, Urbanas gave the I-Team a copy of a letter from CareSource saying the demand letters would stop.
Saying in part, “After direct conversations with providers, CareSource has decided to suspend the recoupment of these overpayments. The providers we spoke to shared that the recoupment would create significant financial strain and could impact access to care for members. That feedback directly informed our decision.”
“Great news, and we appreciate that because hopefully it will give us time to maybe possibly get this resolved. But as of right now, we’re still leery because they are going to make the rates lower for us, the reimbursement rates, going forward,” Urbanas said.
CareSource has previously told the I-Team that it found during a recent review that some behavioral health providers have been historically overpaid for certain services. Adding that it would recoup those overpayments and reimburse those providers at the correct contractual rates going forward.
Last week, the Ohio Department of Medicaid told the I-Team it was looking into whether these CareSource claw-backs comply with legal and contractual timeframes.
Bedell asked on Friday if this decision from CareSource has anything to do with what the state oversight agency found:
“CareSource’s decision to pause certain overpayment recoveries was made independently by the plan.
ODM continues to work closely with all Medicaid managed care organizations to ensure that their claims review and recovery processes comply with state and federal requirements and are implemented consistently and transparently for providers.
We are aware of the concerns raised by behavioral health providers and are actively evaluating plan practices to ensure they align with Medicaid policy and support program integrity. ODM remains committed to protecting both providers and the individuals they serve,” an ODM spokesperson said.
A spokesperson with CareSource shared the following statement from CareSource regarding the change:
“At CareSource, we believe everyone deserves access to compassionate, high‑quality behavioral health care, and we value the providers in our network who make that care possible for our members.
Earlier this month we notified some behavioral health providers in our network that CareSource had inadvertently overpaid them and would be implementing the correct rates consistent with the terms of their contracts, both retrospectively and for future claims. This action did not represent a rate reduction.
After direct conversations with providers over the past several days, CareSource has decided to suspend the recoupment of those overpayments. The providers we spoke to shared that the recoupment would create significant financial strain and could impact access to care for members. That feedback directly informed our decision and the individual providers impacted by this change will be notified.
Future claims will be paid at the correct rate based on the terms of our provider agreements, which apply rates in specific circumstances based on service, provider type and clinical setting. Applicable behavioral services rendered by a licensed or supervised practitioner are reimbursed at 85% of the established Medicaid fee schedule in most cases.
As behavioral health costs continue to rise, CareSource is committed to working with Ohio’s healthcare community to advance a high-quality and sustainable behavioral healthcare system. We look forward to collaborating with the state, providers and other health care partners to ensure access to critical services for Ohioans," the spokesperson said.
News Center 7 will continue to follow this story.
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