A surprise move by CareSource, Ohio’s largest Medicaid managed care provider, is sending shockwaves through the state’s mental health community and raising concerns that care for thousands of patients could be in jeopardy.
CareSource confirmed it will retroactively recoup payments from behavioral health providers in addition to cutting future reimbursements. The reductions — resulting in an 85% reimbursement rate for certain providers, down from the contracted 100% — apply not only to future claims but to payments already made, stretching back to 2024.
In a statement to WCPO, a CareSource spokesperson said the action is part of the organization’s compliance and stewardship responsibilities.
CareSource’s mission is to improve the health and well-being of Ohioans while responsibly managing Medicaid funds to maintain high-quality, affordable care. During a recent review, we identified certain behavioral health claims that were not paid in alignment with the established billing and reimbursement rules. When this occurs, it is our standard practice to work with providers to correct the issue and ensure accuracy.We are notifying affected providers of reimbursement adjustments going forward, as well as the need to recover overpaid funds, in accordance with our fiduciary responsibility. We understand this may cause concerns for some providers, and we are working with them to review individual circumstances and offer flexible repayment options. Throughout this process, we are working closely with state regulators and remain focused on supporting provider network stability and protecting our members’ access to quality care.CareSource Spokesperson
CareSource said such adjustments are standard when payment issues are discovered. But many behavioral health providers say the combination of deep rate cuts and retroactive clawbacks is unprecedented and pushes the mental health care system closer to collapse…