DHCS has published a notice on the Provider Home Page indicating that non-chain pharmacies could begin seeing claw back of payments as early as 1/14/16. They have completed the reprocessing of all impacted claims for all pharmacy providers and now will begin recoupment of 5% in an individual check write. We have printed the notice below. There is no indication as of yet on the timing for the claw back for DME. As we indicated in prior notices an impacted pharmacy provider can ask to have the 5% recoupment amount reduced based upon hardship. You need to contact Xerox for any hardship exemption or changes.
Ten Percent Payment Reduction and Recoupment
for Pharmacy Claims
December 28, 2015
Assembly Bill 97 (Chapter 3, Statutes of 2011) requires the Department of Health Care Services (DHCS) to implement payment reductions of up to 10 percent to most categories of service in the Medi-Cal program, including pharmacy services.
On February 7, 2014, DHCS implemented prospective payment reductions for pharmacy claims with dates of service on or after June 1, 2011. On August 24, 2015, DHCS began the process of retroactively reprocessing pharmacy claims subject to AB 97 reductions.
DHCS originally planned to begin recoupment activities approximately two weeks after each individual pharmacy provider's claims were completely reprocessed. However, since communicating this plan, DHCS has opted to allow pharmacy providers additional time from when a provider's claims are reprocessed to when the actual recoupment occurs.
As of December 10, 2015, all pharmacy claims subject to AB 97 payment reductions have been reprocessed by DHCS. Additionally, providers should expect to see recoupments from future warrants beginning as early as the January 14, 2016 warrant date. Providers may view the checkwrite schedule in the Checkwrite section of the Part 1 provider manual.
