Reconsideration Reviews: The Nuts and Bolts

A reconsideration review is an informal appeal available for the health care provider to appeal a state action entitled a “Tentative Notice of Overpayment” (namely, a Medicaid post payment audit).  The Tentative Notice of Overpayment does not come from DHHS, instead the Notice will come from one of the state’s contracted entities in charge of Medicaid post payment audits.  Public Consulting Group (PCG) and The Carolinas Center for Medical Excellence (CCME) are the main consulting firms.

Asking for a reconsideration review does a couple things immediately:

1. The health care provider does not need to pay the alleged Medicaid overpayment amount.  The request for a reconsideration review, essentially, stays the deadline for the provider to pay any overpayment amount.

2.  It informs DHHS that the health care provider does not agree with the findings in the Notice.

Very important: A health care provider has 15 working days from the receipt of the Tentative Notice of Overpayment to request a reconsideration review.

According to the Tentative Notice of Overpayment, a provider has 30 days in which to submit any documentation in support of the review.

While this 30 day documentation deadline for the provider is written on the Notice, in practice, the 30 days is extremely flexible.  The DHHS Hearing Officer will tell you that PCG (or whatever consulting firm) needs the documents 2 weeks before any reconsideration review.  My suggestion is that if the DHHS Hearing Officer requests documents to be sent 2 weeks prior to the reconsideration review, send the documents 2 weeks prior.  There is no reason to disregard the Hearing Officer’s request.  However there have been occasions in which the Hearing Officer did not request me to send documents 2 weeks prior to PCG, and in this case, I brought the documents to the reconsideration review itself.  Everyone still reviewed the documents. Nothing was excluded. Again, if a Hearing Officer requests the documents 2 weeks prior, make sure to honor the wish.

So what happens at a reconsideration review? Where is it? What is expected? Do I have to wear a suit?

The reconsideration review will be held at the Division of Medical Assistance, located at 333 E. Six Forks Rd., Raleigh, North Carolina 27609.  It will be held in a small conference room with one medium-sized table.  The rooms are not spacious, so consider this when you bring every file from your company.  If you live far away from Raleigh, you can request a telephone conference.  While this may be necessary for some providers, I do not suggest this.  Meeting the people there is an unmeasureable asset.  Getting to know the Hearing Officer and generally demonstrating a positive demeanor will get you far.  This is difficult over the phone.

The people present will be a DHHS Hearing Officer, a representative from the consulting group (most likely, PCG or CCME), a representative from DHHS, the health care provider, and the provider’s attorney, if one was hired.

The review is informal as compared to NC Superior Court.  The Hearing Officer still demands respect and will read a short instructional paragraph prior to the review beginning.  Everyone is sitting at the conference table. You do not need to wear a suit. I suggest looking professional and acting as if you were taking the review very seriously.

After the Hearing Officer reads the instructions, the next step really depends on which Hearing Officer you get. Each Hearing Officer conducts the reconsideration reviews slightly different.  But, basically, the slow, tedious process begins in which the parties go to the first Medicaid recipient with alleged deficiencies and to the very first service date at issue. Most likely you will have hundreds of alleged deficiencies.  The “meat” of the reconsideration review is extremely deliberate and detail-oriented.  When I am present representing a health care provider, I am doing 90% of the talking.  In fact, halfway through the day, I am in desperate need of water.  I am not sure what happens without a lawyer present, but I would venture to guess that the provider is doing most of the talking.

Once the parties have reviewed every Medicaid recipient’s documents for every service date, as well as all employee information requested, the DHHS Hearing Officer will set a deadline for the provider to provide any additional documents (You will always have more to provide. It is virtually impossible to get everything the first time).  This deadline is never far off.  The Hearing Officer is under massive pressure to provide a decision quickly.  If you absolutely need more time, ask the Hearing Officer to get an longer extension authorized by his or her superior.  But beware: the longer extension is days, not weeks.

Then the Hearing Officer will speak to the PCG rep and DHHS rep. They will discuss the turnaround time foe the decision. Most likely, they will also banter about how much pressure they are receiving for quick turnarounds.

Then you will shake hands and the Hearing Officer will escort you out. The next step…..wait for the decision.  It seems like a long time passes before you receive the Decision.

Important Note: You will not agree with the DHHS Hearing Officer’s decision.  While the decision will reduce the amount of alleged overpayment by a bit, the reduction will not be large enough to warrant payment.  In fact, most providers are unable to pay the reduced amount.  At this point, you need to appeal the decision to the Office of Administrative Appeals (OAH). It seems like a lot of work, and it is. There is no denying that. It is a slow and cumbersome process. But when you are told you owe $1.5 million and end up getting it reduced to pennies on the dollar, you will be thankful.

About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on January 7, 2013, in DHHS, Medicaid, Medicaid Appeals, Medicaid Recoupment, North Carolina, OAH, PCG, Reconsideration Reviews and tagged , , , , , , , . Bookmark the permalink. Leave a comment.

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