Care management organization failed to demonstrate authority to recover reimbursements.
Docket Number: 1638270 , Decision Date: August 4, 2016
Attachment: Click here to download the decision.
Peach State Health Plan (Peach State), a care management organization (CMO) sought to recover payments made to JLD, a speech therapy provider, based primarily on its determination that JLD failed to document the duration of speech therapy sessions. However, in the absence of a contract provision holding otherwise, such payments were “voluntary” under Georgia law. Further, the manuals generated by the Department of Community Health (DCH) did not grant recoupment authority to CMOs, and Peach State did not tender into evidence its contract with DCH, which purportedly allowed it to recover payments from providers. Accordingly, Peach State could not recover payments made to the provider.