Contracted NC Agencies Recouping Medicaid: Not Following the Law?

One of my biggest complaints about the NC Medicaid auditing procedures is that services that were prior approved by the correct contracted company, now, at a later date, the prior authorization is being questioned by a, sometimes, different company which determines that medical necessity was not met…despite that medical necessary WAS met earlier.

In all my reconsideration reviews, I have made the “it’s not fair” argument for the health care providers to be told medical necessity was met, only to be told later that medical necessity was not met. I mean, can it get any more confusing?  The only answer I received from DMA representatives was that this “look-back audit” is allowed by federal and state law.

I agree that audits are allowed by federal and state law.  I do not agree that overturning past authorization of medical necessity is allowed by federal and state law.

N.C. Gen. Stat 108C-7(c), which regulates prepayment reviews, states, in pertinent part:

“For any claims in which the Department has given prior authorization, prepayment review shall not include review of the medical necessity for the approved services.”

Shall NOT include review of medical necessity.  Shall not.  Yet, in reconsideration reviews, I am, over and over again, arguing with Department representatives that this particular Medicaid recipient met medical necessity.

Shouldn’t someone tell the Department and the recoupment auditing companies that prepayment review shall not include review of the medical necessity?


About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on February 26, 2013, in CCME, Division of Medical Assistance, Health Care Providers and Services, Legal Analysis, Medicaid, Medicaid Audits, Medicaid Reimbursement, NC DHHS, North Carolina, RAC and tagged , , , , , , , , . Bookmark the permalink. 2 Comments.

  1. I think you just did. 🙂

    Actually, that sounds like a job for the State’s chief legal officer, your old boss, the AG.

    It sounds like the current harassment approach might be illegal.

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