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 within three months of payments on “inlier” claims. The confusion regarding timing arose because of a brief break in the Medicaid recipient’s admission to MCCG’s facility, leading MCCG to file multiple inlier claims.  Judge Schroer held that the final inlier claim triggered the running of the three months in which to submit the outlier claim.  She based her decision on the action of the parties, which demonstrated intent to depart from the original terms of the contract.  Because the outlier claim was within three months of the processing of the final inlier claim, Peach State’s decision to deny the claim for untimeliness was reversed.

Judge Schroer’s decision was affirmed on appeal.

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