Providers: ALF Overpayment Recovery Notice
Date: 03/11/21
Fort Lauderdale, Forida
Valued Assisted Living Facility Providers:
We appreciate your service and dedication to our Long Term Care members. Your personalized care improves their quality of life and enables them to live as independently as possible.
Sunshine Health recently completed an audit of Assisted Living Facility (ALF) patient responsibility payments and associated claims. You may have recently received an Overpayment Recovery Notice that identified your ALF as having received an overpayment related to patient responsibility. Patient responsibility refers to the amount of money that residents are required to pay each month to an ALF as part of the total cost of care. The Patient Responsibility amount is calculated by the Florida Department of Children and Families (DCF) and is available for providers to access for each resident on DCF’s portal, “DCF Provider View.”
Sunshine Health’s approach to ensuring our ALF providers receive full payment for services is to delegate the collecting of the monthly patient responsibility amount to the ALF. This way, the ALF receives the payment directly from the resident each month. An example of this would be the following: Per DCF Provider View, the resident has a patient responsibility amount of $50 and the ALF is contracted at $1,200 per month with the health plan. The ALF would collect $50 from the resident and bill the health plan for the remaining $1,150.
In many cases, overpayments result from billing the health plan without first collecting the patient responsibility amount from the resident and then deducting it from the contracted rate prior to submitting the claim for payment. We recognize that identifying the correct patient responsibility amounts each month can present a challenge. To support you, we offer a training on this topic and other ALF-related guidance. Register for a training session at SunHealthFL.com/ALFTraining.
We value the partnerships of our ALF network, and offer several options for you to select from for payment reconciliation, including choosing a payment by check option or choosing to withhold claim payments from future claims. Our team will work with you individually to identify the best option for you and to help ensure that billing and claims payment are aligned to avoid future overpayments and recoupments.
If you believe our records are in error, you can dispute the payment by mail to:
Sunshine Health/Provider Dispute Resolution
P.O. Box 3070
Farmington, Mo. 63640-3823
The request must include: name, address and phone number of provider of service; provider’s Sunshine Health National Provider Identification (NPI) number and Tax Identification Number; a complete and accurate explanation of the issue; and supporting documentation, including copies of claims if applicable, claim numbers, medical records or other supporting documentation. We will process your dispute within 30 business days.
If you have questions or need assistance, please call Provider Services at 1-844-477-8313. We are here to help.
Again, we value our partnership and want to work together to ensure our billing practices and claims payment processes are aligned.