Log in

State Supreme Court Issues Ruling in Medicaid Cost Recoupment Case

August 03, 2020 9:41 AM | WiAHC Office (Administrator)

This month, the Wisconsin State Supreme Court issued an opinion in the case of Papa v Wisconsin Department of Health Services. The case, brought by Professional Homecare Providers, Inc., sought to resolve an issue in which the Department of Health Services was recouping Medicaid payments made to private-duty nurses after auditing their records.

DHS recouped between $15,000 and $48,000 each from four separate private-duty nurses after audits found errors in notes and medical records. In other, DHS recouped costs for the way records were written, not because of fraudulent claims. Professional Homecare Providers, Inc. sued the state because of this documentation “perfection policy” created by DHS.

The State Supreme Court sided with the nurses, stating in the ruling, “There is no legal basis for the perfection policy.”

Writing the unanimous opinion, Justice Annette Ziegler said, “We conclude that…DHS may recoup Medicaid payments from service providers only in cases where DHS cannot verify one of the following: (1) the actual provision of covered services; (2) that the reimbursement claim is appropriate for the service provided; and (3) that the reimbursement claim is accurate for the service provided.”

While the case was brought by private-duty nurses, the ruling applies across the board to all Medicaid providers and clarifies the only justifications for DHS to recoup payments as stated by Justice Ziegler.

Powered by Wild Apricot Membership Software