Monthly Archives: October 2012

Tip #2 for Medicaid Recoupment Avoidance

Today’s daily tip for Medicaid recoupment avoidance is more of a cautionary tip rather than how to avoid recoupments. Providers: KEEP YOUR DOCUMENTS.  This is imperative. When a provider receives a Tentative NOtice of Overpayment, that provider will need to pull every document pertaining to the Medicaid recipient in question on the service date in question. Medicaid regulations dictate that providers maintain these documents, even years after discharging the Medicaid recipient. Today, with so much online, it is important to keep all the service authorizations, even if providers obtained the authorization via internet. Print off every computer screen showing an authorization. If you maintain your files electronically, make sure your system maintains these records.

Having all documents will be invaluable if you receive a Tentative Notice of Overpayment.

Also, if you do receive a Tentative Notice of Overpayment, you have FIFTEEN (15) days to appeal!! (Or request a reconsideration review).

Avoiding Medicaid Recoupment from the State #1

Always ensure that the doctor signs the service order BEFORE the initial date of service.

Sound silly and obvious? I have had many recoupment actions in which the doctor either (a) failed to date the signature; (b) wrote the date illegibly; (c) the service notes are dated before the service order.

These small details are imperative to a successful Medicaid health care provider and avoiding recoupments from the state.

Planned Parenthood Going to Court Over Medicaid Dollars!

Planned Parenthood has taken its fight for Medicaid funds to state court, claiming Texas illegally eliminated affiliates of abortion providers from a health care program for low-income women.  

The Texas state Legislature passed administrative rules in 2011 that bar health care providers who participate in the mostly federally funded Women’s Health Program (WHP) from performing or promoting abortions, or from affiliating with entities that do.     

The Centers for Medicare and Medicaid Services responded by pulling federal funding from the state program altogether. Texas sued the U.S. Department of Health and Human Services over the lost funding and will go to trial in March 2013. Planned Parenthood estimates that if it does not prevail, it will lose over $13 million in funding per year, resulting in Planned Parenthood closing clinics, reducing hours, and laying-off employees.  PP states that this reduction in women care would be devastating to women in Texas. WHP is authorized as a Medicaid program if the federal funding is allowed. No federal funding…no WHP.

The next hearing is November 8th.

Could receiving federal disaster relief lose your Medicaid eligibility?

President Obama has declared portions of NY and NJ a federal disaster. In the wake of a natural disaster, most presidents have declared the areas national disasters. By doing this, the president allows a well-funded government agency known as FEMA to provide federal funds to the disastrous area. Housing, food and medical supplies and service are provided by FEMA. In some cases, FEMA will provide low monthly stipends for mortgages and rent.

Does this increased income violate a Medicaid recipients’ eligibility? NO! The federal government has provided an exception to income received in the wake of a natural disaster. So all the innocent victims in the north east, rest a little easier, any aid you receive from FEMA does not count as income. I know it is a small consolation. Being from NC, I have endured a number of hurricanes. Our prayers are with you.

Defunding Planned Parenthood?

North Carolina is trying. We are one of 6 states that has legislatively attempted to defund Planned Parenthood, but the courts have blocked all six. Obviously, this attempt to defund Planned Parenthood is based on politics. The whole intense debate surrounds Medicaid dollars, supposedly used for indigent citizens and mentally or physically disabled persons, which are being sent to Planned Parenthood and, in part, used to fund abortions. Anti-planned parenthood-ites opine that Planned Parenthood provides services for people outside the realm of Medicaid, i.e.,  rich, pregnant teen A gets an abortion so her parents never know she was pregnant. Teen A does not qualify for Medicaid; therefore, it is in violation of Medicaid regulations to provide Teen A Medicaid services. I get that. I understand the black letter law. However, conservative advocates are not presenting the argument like this. Instead, conservatives are arguing that the government should not fund abortions, which creates emotionally-charged retorts, instead of educational banter. Based on the fact that Medicaid dollars are only allowed for those persons who qualify for Medicaid, and only that fact, the courts may have it wrong here. Maybe it IS in violation of Medicaid rules to allow all women to undergo Medicaid-funded abortions. However, my opinion does NOT make me pro-life. Instead, I am pro-get-the-government-following-the-Medicaid-rules-and-stop-regulating-beyond-its-scope. 

The HUGE Quandary of Medicaid’s Future

I am pro-Medicaid. Our country needs it. Providers do a great service by helping Medicaid recipients. However, with the overwhelming deficit we have created, change to Medicaid is coming…good or bad. It has to. And I am also anti-deficit. So which presidential candidate will revamp Medicaid for the better? Well, it depends how you look at it.

With Romney, he will repeal Obamacare. Repealing the health care reform law would reduce Medicaid spending by $618 billion over the next 10 years, according to the Center on Budget and Policy Priorities and Romney’s additional cuts would mean a total of at least $1.4 trillion in cuts over a decade. Under Romney’s block grant proposal, between 14 million and 27 million fewer people would be covered in 2021 than under Medicaid as it currently exists, according to an Urban Institute analysis. With less money, states are certain to reduce benefits and ask recipients to pay more for care, among other changes.

With Obama,starting in 2014, Medicaid coverage will be expanded to everyone with incomes less than 133 percent of the federal poverty level, which today is nearly $31,000 for a family of three. The federal government pays the full cost for those newly eligible for Medicaid from 2014 to 2016, then states have to begin to contribute to the cost but no more than 10 percent by 2020.

Clearly, the summary is that Romney will reduce Medicaid and save trillions of dollars; Obama will expand Medicaid and increase spending by trillions of dollars.

Which is better? Depends on whether the deficit or Medicaid is more important to you.

Health Care Providers: Where Do You File an Appeal?

It depends.

For a Notice of Overpayment? Providers should request a reconsideration review and hire an attorney.

For a denial of endorsement? Providers have very limited time to appeal a denial. Hire a lawyer. Appeal as the denial explains.

For a Medicaid recipients’ rights? Most appeals will be to the Office of Administrative Hearings (OAH).

I wrote the above “blog” back in 2012. It was one of my first blogs and one of my shortest. Looking back, I must admit that the blog is not even good…it’s accurate-ish. I cannot believe that I have been blogging for over 10 years of my life…and about Medicare and Medicaid regulatory compliance litigation — who knew?

As the year ends, I want to thank all my readers for reading this blog for TEN YEARS. I am humbled and appreciative. As all of you are aware, I do not get paid to blog about Medicare and Medicaid. It actually eats-up quite a lot of my time, which I do not have in Spades, as a mother of a Senior in HS, a wife, and an attorney.

Now I will rewrite the 2012 blog for 2022-2023:

Health Care Providers: Where Do You File an Appeal?

If you are filing a Medicaid provider appeal claiming that you do not owe an overpayment, your State will have an administrative process for you to seek redress. You must exhaust administrative remedies, so read the notice of overpayment for clarification of the 1st and maybe 2nd steps. You normally have a reconsideration and a red-determination before presenting to an administrative law judge.

Hire a lawyer from the beginning.

If you are filing a Medicare provider appeal, see blog. Still hire an attorney.

I look forward to another year of defending health care providers against the State and federal governments. I see it as I have the chance to keep health care providers in business and accepting Medicaid and Medicare. Thank you for accepting Medicare and Medicaid, and I will be here to fight!! I have represented providers from Alaska to New Mexico to New York and Florida and all in between!

3 new, Wake County, operating rooms awarded to Holly Springs Surgery Center over Rex

The North Carolina Court of Appeals held that the new Wake County operating rooms should be awarded to Holly Springs Surgery Center, despite Wake Med/Rex’s protests. Wake Med/Rex claimed, among other things, that Holly Springs’ Medicaid and charity programs were a sham. The Court of Appeals disagreed and held that the need for the surgery rooms belong to the patients, not the hospital.

Tentative Notices of Overpayment

Recently, I have seen a huge increase in the number of overpayment notices from the state. The notices come from PCG, which is a state-contracted company. It’s amazing the amount that these notices claim is due back to the state. I’ve seen a claim for as high as $545,000. Obviously, these notices, if correct, would put most small health care providers out of business. Then Medicaid recipients would have no providers. I have been successful at appealing these notices. For one notice, I settled with the state for LESS than 1% of the claim. (Disclaimer: I do not promise these results!!). However, the important point is: you can fight these notices of overpayment. Hire a lawyer.

Basic Medicaid and NC Health Choice Billing Guide- New October 2012

As of October 2012, the Basic Medicaid billing guide has been updated.  Make sure to read the new updated Medicaid billing guide.

Click to access Compilation_1012.pdf