Retro Billing Concerns
Approximately 32 percent of Medi-Cal beneficiaries also have Other Health Coverage (OHC). Of this figure, approximately 60 percent is a form of Medicare. When Medi-Cal learns that a beneficiary has OHC after remunerating a provider's claim, Medi-Cal may directly bill the OHC carrier for the amount Medi-Cal paid or recoup the payment and allow the provider to bill the OHC carrier directly. If the carrier will not accept claims from Medi-Cal or a provider's Medi-Cal contract prevents direct carrier claims, Medi-Cal may recoup the payment so the provider may bill the OHC carrier directly. In most cases, a provider receives a higher reimbursement from a carrier. This is a predominate reason many providers find the latter option most beneficial to their organization.
Two contractors work on behalf of the Department of Health Care Services for retro billing recovery efforts concerning OHC, Xerox and Health Management Systems (HMS). Xerox recovery efforts focus predominately on Medicare Part A and Part B. HMS recovery efforts focus predominately on commercial (private) coverage, Medicare Part D, and secondary reviews for Medicare Part A and Part B.
What Do I Do if I Receive a Retro Bill?
If you received a retro bill, please follow the instructions from the recovery contractor to ensure that Medi-Cal recoups only once and you receive your payment from the OHC carrier as expeditiously as possible.
If you are a provider, send a claim to Medicare or the OHC carrier. If Medicare or the OHC carrier rejects your claim for untimely submission, the provider should appeal these rejected submissions. If you receive an Explanation of Benefits, Medicare Common Working File, or some other carrier notice that denies benefits after appealing, please provide this information directly to the recovery contractor. Otherwise, the recovery contractor may establish an account receivable to recoup the Medi-Cal payment.
If you see a claim retroactively voided on your remittance advice detail, please file your claim with the OHC carrier as you would for any other retro bill.
What Do I Do if DHCS Recouped an Amount in Error?
Please contact the recovery contractor you received the notice from first.
If your concerns are not being addressed, complete the Retro Billing Concerns Notification Form and DHCS will follow up with our recovery contractor. Please attach scanned copies of your documentation in PDF format which will allow DHCS to assist in the resolution of your inquiry.
Back to TPLRD Home Page