Recoupment of Medicaid payments only justified by clear violations of policy.

The Georgia Department of Community Health (DCH) was authorized to recoup payments made to a Medicaid provider for one of three alleged violations.  Specifically, it could recoup payments where the provider did not comply with the Provider Manual’s requirement to include Body Mass Index (BMI) calculations as part of nursing assessments.  However, it could not recoup payments where no date accompanied a consumer’s signature on a Care Plan, because the policy does not require that the consumer both date and sign the plan.  In addition, because state-generated electronic program does not offer “annual” as an option in its drop-down menu, DCH could not recoup payments where the provider indicated quarterly assessments in the drop-down menu but clarified elsewhere that assessments would be done on an annual basis.