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Modern Healthcare - - REGIONAL NEWS -

SALEM, Ore.—

Ore­gon re­ceived fed­eral ap­proval and prom­ises of en­hanced Med­i­caid fund­ing to be­gin treat­ing thou­sands of pa­tients through provider net­works called co­or­di­nated-care or­ga­ni­za­tions whose goal is to use preven­tion and co­or­di­na­tion of men­tal and phys­i­cal health­care to re­duce over­all costs (May 7, p. 6). The CMS ap­proved Ore­gon’s Med­i­caid demon­stra­tion pro­gram, which comes with $1.9 bil­lion in ad­di­tional fund­ing over five years to help im­prove and co­or­di­nate care for many of the state’s 600,000 Med­i­caid re­cip­i­ents. That in­cludes 39% of the chil­dren in the state and 16% of the to­tal pop­u­la­tion. The state has cer­ti­fied eight co­or­di­nated-care or­ga­ni­za­tions to be­gin serv­ing 20 coun­ties start­ing Aug. 1 and granted pro­vi­sional cer­ti­fi­ca­tion for six more CCOS that would be­gin serv­ing 19 coun­ties on Sept. 1, in­clud­ing the closely watched Tricounty Med­i­caid Col­lab­o­ra­tive cov­er­ing the Port­land-area coun­ties of Clacka­mas, Mult­nomah and Wash­ing­ton. Those 14 CCOS are expected to cover about 90% of the state’s Med­i­caid pop­u­la­tion, state of­fi­cials have said. The pro­gram is pro­jected to save about $11 bil­lion over 10 years. Al­though states across the coun­try are ex­per­i­ment­ing with Med­i­caid-based ac­count­able care-style or­ga­ni­za­tions, Ore­gon of­fi­cials have said they be­lieve their pro­gram is dif­fer­ent be­cause of its locally con­trolled bud­get frame­work, em­pha­sis on pre­ven­tive care, and co­or­di­na­tion of med­i­cal, men­tal and den­tal care.

SACRA­MENTO, Calif.— An­them Blue Cross re­ceived an or­der from the Cal­i­for­nia Depart­ment of Man­aged Health Care to stop try­ing to re­coup over­pay­ments on old med­i­cal claims. The state depart­ment said that be­tween 2008 and 2011, An­them sought re­im­burse­ment from 535 providers for over­pay­ments on med­i­cal claims that were more than a year old. Un­der Cal­i­for­nia law, health plans have only a year to re­coup over­pay­ments on med­i­cal claims un­less they can show that a provider en­gaged in fraud or mis­rep­re­sen­ta­tion. The depart­ment said its in­ves­ti­ga­tion found no in­di­ca­tion that An­them had ev­i­dence of fraud or mis­rep­re­sen­ta­tion on the part of the providers. An­them Blue Cross spokesman Dar­rel Ng said in an e-mail that the health plan sought re­im­burse­ment for over­pay­ments re­sult­ing from dou­ble-billing of the same ser­vice—which is con­sis­tent with Amer­i­can Med­i­cal As­so­ci­a­tion guide­lines. “An­them Blue Cross be­lieves med­i­cal providers should be com­pen­sated for ser­vices pro­vided, but should not re­ceive pay­ment twice for the same pro­ce­dure,” he said. “We will closely ex­am­ine the ac­tion by DMHC and are con­sid­er­ing our op­tions.” In a news re­lease about the or­der, Brent Barn­hart, di­rec­tor of the Depart­ment of Man­aged Health Care, said the law pro­tects health providers who were “act­ing in good faith.” “Health­care providers should not face un­ex­pected de­mands for re­im­burse­ment of med­i­cal claims they be­lieve were ap­pro­pri­ately paid years ago,” he said.

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