Delayed Refund Following Retroactive Medicaid Approval
Penalty
Summary
The facility failed to provide a timely refund to a resident's family member after the resident's Medicaid application for long-term care services was approved retroactively. Documentation showed that the family member had made two private payments totaling $7,853 while the Medicaid application was pending. The facility's admission packet stated that if Medicaid coverage is retroactive for a period for which payment has already been made, the facility would refund or credit any excess amount within thirty days of Medicaid eligibility being established. However, interviews with the Business Office Manager and Accounts Receivable Manager revealed confusion and lack of awareness regarding the status of the refund, with the Accounts Receivable Manager only being alerted to the balance due back to the family member months after Medicaid approval. The resident was initially covered by a Medicare Advantage plan, which later discontinued skilled services, leading to the resident being considered private pay until Medicaid approval. The resident's Social Security check was used for the patient portion of payment, and the family member shared a bank account with the resident, complicating the determination of the funding source. Despite the facility's policy and the retroactive Medicaid coverage, the refund process was delayed, and staff were unclear about the procedures and status of the refund owed to the family member.