Court: Documentation lacking in dual eligibles claims

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A California hospital group will not receive reimbursements for some Medicare/Medicaid dual eligibles claims because it lacked proper documentation, a federal appeals court has ruled.

The  court's ruling of insufficient documentation could set a precedent for long-term care operators managing dual eligibles.

Grossmont Hospital Corp. submitted its own payment estimates to Medi-Cal, California's Medicaid agency, after realizing it wasn't paid for some dual eligibles claims. The corporation said it wasn't paid due to problems with Medi-Cal's automatic claim system. The agency, however, denied payment, determining the hospital's documentation wasn't appropriate.

Grossmont originally took its case to the Provider Reimbursement Review Board, which decided the hospital group had sufficient documentation and reversed Medi-Cal's decision. But the state appealed, and Department of Health and Human Services Secretary Sylvia Burwell reversed the board's decision. She cited a longstanding policy that prevents payment of dual eligibles claims “unless the hospital first billed the state Medicaid agency and obtained a determination from the state of its payment responsibility.”

The U.S. Court of Appeals for the District of Columbia Circuit upheld Burwell's ruling August 7.