Failure to Bill Managed Medicaid Results in Improper Discharge Notice
Penalty
Summary
The facility failed to ensure that the basis for a resident's discharge met the required criteria, specifically regarding the handling of payment and insurance claims. A resident with intact cognition was admitted with coverage through a Managed Medicaid plan, but the facility listed the payer source as private pay and did not submit a claim to the insurance for payment. As a result, the resident was issued a 30-day discharge notice for non-payment, despite having insurance coverage that should have been billed. The resident and their representative were not expecting the discharge and had planned for a longer stay to arrange for accessible housing. The representative also reported receiving ongoing billing statements totaling over $50,000, with no indication that insurance had been billed or had paid any portion of the charges. Interviews with facility staff revealed that approval for the resident's stay had been obtained from the Managed Medicaid plan, but due to the incorrect payer source designation, no claim was submitted. The Business Office Manager confirmed that the process to transition the resident to long-term traditional Medicaid was not initiated as required, and the Administrator was unaware that the insurance had not been billed. The discharge notice was issued based on non-payment of a presumed co-payment amount, but staff acknowledged that co-payment amounts are typically determined only after a claim is submitted. The former Business Office Manager, who may have had further information, was unavailable for interview.