Contract provisions prevail when terms are clear for recoupment.

Topic: Care Management Organization, Decided by Judge Schroer 
Docket Number: 1325889 , Decision Date: 2013-07-29 
Attachment: Click here to download the decision. 

Where a contract provides for two methods of payment, the Care Management Organization is permitted to compensate the hospital at the lower rate and recoup payments made at the higher rate as erroneous.

Medicaid “outlier” claim was timely filed due to mutual action amending terms of contract.

Topic: Care Management Organization, Decided by Judge Schroer 
Docket Number: 1227794 , Decision Date: 2012-08-20 
Attachment: Click here to download the decision. 

Peach State Health Plan, a private Care Management Organization, acting as agent of the Department of Community Health, denied the Medical Center of Central Georgia’s (“MCCG”) request for “outlier” payments (i.e., payments for unusually expensive services) for untimeliness.  By contract, outlier claims must be made [..] Read More..