In a decision released earlier today, the Wisconsin Supreme Court set explicit limits on the Wisconsin Department of Health Services’ (DHS) authority to recoup payments made by Wisconsin Medicaid based solely on technical documentation errors.
The case, Papa vs. Wisconsin Department of Health Services, involved the extent of DHS’ authority to require repayment from providers for previously paid claims based on failure to follow all documentation and other technical requirements contained in a confusing series of administrative rules in the Forward Wisconsin Provider Handbook, technical bulletins and other sources. In 2016, a Waukesha County Court found that DHS’ position that compliance with all technical and documentation requirements by providers as a prerequisite for payment amounted to a “Perfection Rule” that exceeded its authority to recoup payments otherwise properly made. However, the Wisconsin Court of Appeals overturned that decision in July 2019.
In today’s 6-0 decision, the Supreme Court reversed the Court of Appeals and restored the county court’s 2016 order limiting DHS’ authority to recoup payments, concluding that “so long as DHS can verify that a covered service was actually provided, the claim was appropriate, and the claim was accurate, DHS cannot recoup payments based on a record imperfection. A record imperfection alone is not an independent basis for recouping payments.” The decision provides clarity and greater certainty for physicians, who could otherwise face demands for repayment of thousands of dollars months or years after the fact based entirely on unintentional documentation errors.
“This is an important case for physicians, but more importantly for patient access to our Medicaid system,” said Wisconsin Medical Society (Society) CEO Bud Chumbley, MD, MBA.
The Society was part of a collation of state health care associations that filed amicus briefs in both the Court of Appeals and the Wisconsin Supreme Court advocating for elimination of the Perfection Rule. According to the briefs, health professionals already face additional administrative burdens and lower reimbursement in treating Medicaid patients. The possibility of having payments revoked after the fact where there is no question whether services were provided, covered or necessary threatens clinicians’ ability to participate and ultimately adequate access to care for Medicaid participants.
“We look forward to our continued work with DHS and other stakeholders to ensure adequate access to care for some of our state’s most vulnerable citizens while also protecting the integrity of our Medicaid system,” added Dr. Chumbley.
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