BLUE ASH, Ohio \u2014 A surprise move by CareSource, Ohio\u2019s largest Medicaid managed care provider, is sending shockwaves through the state\u2019s mental health community and raising concerns that care for thousands of patients could be in jeopardy. <\/p>\n
CareSource confirmed it will retroactively recoup payments from behavioral health providers in addition to cutting future reimbursements. The reductions \u2014 resulting in an 85% reimbursement rate for certain providers, down from the contracted 100% \u2014 apply not only to future claims but to payments already made, stretching back to 2024.<\/p>\n
In a statement to WCPO, a CareSource spokesperson said the action is part of the organization’s compliance and stewardship responsibilities. <\/p>\n
CareSource\u2019s 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.<\/p>\n
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\u2019 access to quality care.<\/p>\n
CareSource Spokesperson<\/p>\n
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.<\/p>\n
WATCH: Ohio mental health providers sound alarm over CareSource Medicaid payment clawbacks<\/p>\n
Ohio mental health providers sound alarm over CareSource Medicaid payment clawbacks<\/p>\n
In Blue Ash, Alexandria Fields, owner of Inclusive Counseling, said she learned of the change the same way many providers did \u2014 through social media therapist groups.<\/p>\n
\u201cI kind of woke up to complete chaos,\u201d Fields said. \u201cAnd at first I’m thinking, I’m sure it’s nothing. We’ll figure it out. And as I go through, I find that actually it’s true.”<\/p>\n
Inclusive Counseling has 30 therapists and about 800 active clients. Around 40% are on Medicaid, and CareSource accounts for roughly a quarter of the practice\u2019s claims. Fields said she’s already seen more than 500 recoupment notices just for March through May of 2024.<\/p>\n
She said she estimates the clawbacks on those will total close to $100,000 for her business alone.<\/p>\n
\u201cTo lose 15% all at once, withheld from future payments, is very scary,” Fields said. “It’s a catastrophic amount of money.”<\/p>\n
Fields said losing that funding will have ripple effects far beyond her ledger.<\/p>\n
“If you\u2019ve ever had a therapist you really connect with, you know how hard it is to replace that. If practices close or drop CareSource, many people will have to start over, and some may never find a new fit,” Fields said. “For people managing trauma, depression, PTSD or anxiety, suddenly losing your provider can set back progress dramatically. This isn\u2019t just inconvenient. For some patients, it can be dangerous.\u201d<\/p>\n
Monica Hill, who owns Untangled Thoughts LLC, a solo outpatient psychotherapy practice in Midland, said the retroactive adjustments threaten solo practices just as much as larger ones.<\/p>\n
Hill sent the following in an email to WCPO: <\/p>\n
\u201cCareSource has issued retroactive reimbursement adjustments and recoupment notices for previously paid claims, citing internal reimbursement or \u2018market requirement\u2019 updates. These are not billing errors on my end. The claims in question were submitted correctly, processed, and reimbursed at the contracted rate at the time of service,” Hill said. “Applying recoupments in this manner undermines reimbursement reliability and raises serious concerns about the validity of post-payment reversals without clear, upfront contractual or policy disclosure.\u201d<\/p>\n
Hill said the clawbacks create \u201cimmediate financial instability\u201d and \u201cforce difficult operational decisions that directly affect patient access to care,\u201d particularly in communities with already limited mental health resources.<\/p>\n