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.