Special Notice / Hearing: None__
Vote Required: Majority
To: Honorable Board of Supervisors
From: Colleen Chawla, Chief, San Mateo County Health
Chester J. Kunnappilly, MD, Chief Executive Officer, San Mateo Medical Center
Subject: Agreement with Crossroads Health LLC to Provide Overpayment and Credit Balance Resolution Services
RECOMMENDATION:
title
Adopt a resolution authorizing an agreement with Crossroads Health LLC to provide overpayment and credit balance resolution services, for the term of April 1, 2026 through March 31, 2029, in an amount not to exceed $2,630,000.
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BACKGROUND:
In accordance with Medicare and Medicaid program integrity provisions, credit balances on accounts receivables must be identified, and an overpayment resolution initiated to return the funds to the payor within 60 days after discovery. San Mateo Medical Center (SMMC) is responsible for achieving its goals relating to the compliant, accurate, and timely resolution of credit balances and overpayments. In December 2025, SMMC completed a Request for Proposals, and Crossroads was elevated due to their documented effectiveness in resolving overpayments and credit balances.
DISCUSSION:
SMMC continues to have a critical need for overpayment and credit balance resolution services. Crossroads will be providing SMMC with both credit balance resolution and overpayment correction, which includes any associated audit and Claims Inquiry Form (CIF) requirements. CIF is the process required by State Medi-Cal in order to recoup overpayments. This agreement is going to this Board late due to prolonged negotiations with the vendor.
The County Attorney has reviewed and approved the resolution and agreement as to form.
The resolution contains the County’s standard provisions allowing amendment of the County fiscal obligations by a maximum of $25,000 (in aggregate).
The Technology Services Department has reviewed and approved the IT component of this agreement.
It is anticipated that 100% of SMMC’s credit balances in accounts receivables will be identified and a resolution offered to the payor within 30 days of discovery; 98% of accurate payer, amount, and reference information accuracy without duplication (multiple submissions of the same refund); and 98% successful resolution to the overpayment, within 45 days after offer is made to payor.
PERFORMANCE MEASURE:
|
Measure |
FY 2025-26 Estimated |
FY 2026-27 Projected |
|
Percentage of SMMC’s credit balances in accounts receivables identified and a resolution offered to the payor within 30 days of discovery |
100% |
100% |
|
Percentage of accurate payer, amount, and reference information accuracy without duplication (multiple submissions of the same refund) |
>98% |
>98% |
|
Percentage of successful resolution to the overpayment, within 45 days after offer is made to payor |
98% |
98% |
COMMUNITY IMPACT:
Crossroads’ overpayment and credit balance resolution services positively impact equitable health care delivery by ensuring that services provided to County patients are appropriately documented, charged, and billed correctly. SMMC’s patients span a wide spectrum of races, ethnicities, gender, and gender-identities. Since November 1, 2024, half of the specialty care patients at SMMC were female and half were male, with the largest ethnic cohorts being Hispanic or Latino (58%) and primarily Spanish-speaking (48%).
FISCAL IMPACT:
The term of the agreement is April 1, 2026, through March 31, 2029. The amount of the agreement is not to exceed $2,630,000 for the three-year term. Funds in the amount of $219,167 are included in the SMMC FY 2025-26 Adopted Budget. Funds in the amount of $876,667 will be included in the SMMC FY 2026-27 Recommended Budget.
The payment provisions and levels of services in this contract differ from those of the previous contract, due to the previous agreement’s underestimated volume of audit needs and changes in credit-balance estimation by 76%. SMMC projects a higher monthly volume of accounts for resolution for credit balances and overpayments. The total value of the new contract represents a 35% increase compared to that of the previous contract.
Expenses at SMMC are covered by fees for services or third-party payors whenever possible. The portion of expenses for services provided to the medically indigent or to those covered by programs that do not meet the full costs of care is covered by the County’s General Fund contribution to SMMC and is within the existing annual appropriation.
ATTACHMENT:
RFP Matrix