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Legislative Success - Clawbacks Now Limited to 12 Months!

Friday, August 2, 2019   (0 Comments)
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After many years of advocacy by both MPA and other organizations, we have finally enacted legislation limiting clawbacks to 12 months following submission of the claim. Governor Baker included the anti-clawback amendment in the final budget for 2020! 
Here are the specifics:
  • The rule goes into effect on July 1, 2019 (it's retroactive since that's the first day of the new fiscal year).
  • A health plan can impose a retroactive denial (clawback) as long as it has been less than 12 months since the claim was submitted.
  • If a health plan does impose a retroactive denial (clawback) within that time frame, they have to furnish the provider with a written explanation of the reason and, when applicable, a description of the additional documentation or any other corrective action required for payment of the claim. Providers must be allowed 30 days to submit that additional documentation or to take other corrective action.
  • This does not apply to claims that are fraudulent, claims that are the subject of legal action, situations where the provider was already paid or the insurance already paid for those services, or the services were not delivered by the provider.
  • Keep in mind that payment integrity audits are not included in this limit, since those audits are done to determine if a provider is adhering to the contract that they signed with the health plan.
Other Highlights from the 2020 Budget:
  • $1 million increase for the DMH Rental Subsidies, meaning approximately 80 additional individuals who are homeless, unstably housed, or stuck in inpatient settings will have access to secure, stable, affordable housing.
  • $10 million for a new Behavioral Health Outreach, Access, and Support Trust Fund. This includes $500,000 earmarked for a public awareness campaign to promote the awareness and use of available behavioral health services, and $2 million for a loan forgiveness program for mental health professionals.
  • $2.8 million restored for child and adolescent services of the $3 million that was cut last year.
  • $500,000 for jail diversionary adult services was restored following previous cuts.
  • An additional $500,000 put into the Center for Police Training in Crisis Interventions

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