CareSource said it will retroactively recoup Medicaid payments from some Ohio behavioral health providers and reduce future reimbursements to 85% from 100%, ABC affiliate WCPO 9 reported April 22.
The changes apply to both new claims and payments already made dating back to 2024, the report said. CareSource said the adjustments follow a review of claims not paid in alignment with billing and reimbursement rules.
Providers said the combination of reduction rates and retroactive clawbacks is “unprecedented” and could destabilize mental healthcare access, according to the report. One Ohio practice reported more than 500 recoupment notices for claims from March 2024 through May 2024, totaling close to $100,000.
Another provider who received a retroactive reimbursement adjustment and recoupment notices said in an email to WCPO, “These are not billing errors on my end. The claims in question were submitted correctly, processed, and reimbursed at the contracted rate at the time of service.”
State Rep. Karen Brownlee, D-Symmes Twp, criticized CareSource’s planned recoupments and said they stem from administrative errors by the payer, according to an April 23 news release. She also said the move highlights broader issues with Medicaid administration in Ohio and led her to introduce the Medicaid Saving Act.
A CareSource spokesperson said, “The action is part of the organization’s compliance and stewardship responsibilities,” and “such adjustments are standard when payment issues are discovered.” The insurer added that it is working with providers on repayment options, and that the changes do not affect every provider in its network, according to the report.
A petition to state officials calls for a pause on the 15% clawback and greater transparency around the policy, citing risks to patient access and provider stability.
This comes as state Medicaid budgets are estimated to decrease by $664 billion through 2034 following the signing of HR 1.
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