NCGS 108C-7 Violates Federal Law
North Carolina health care providers are being placed on prepayment review. A prepayment review is when Program Integrity (PI) withholds Medicaid reimbursements from a health care provider until the provider can show 3 consecutive months of at least 70% accuracy rates. So far there have been boundless errors on the part of the Division of Medical Assistance (DMA) and its agents.
But what about the actual North Carolina General Statute that allows prepayment reviews? Was the statute written in accordance with federal law?
NCGS 108C-5 states, “(a) The Department may suspend payments to a provider in accordance with the requirements and procedures set forth in 42 C.F.R. § 455.23. ”
42 C.F.R. 455.23 states:
(f) The decision to place or maintain a provider on prepayment claims review does not constitute a contested case under Chapter 150B of the General Statutes. A provider may not appeal or otherwise contest a decision of the Department to place a provider on prepayment review. (2011-399, s. 1.)
Ok, so the federal law states an administrative hearing must be allowed “where State law so requires.” North Carolina does not allow for an administrative hearing.
North Carolina is allowed to not allow for an administrative decision, right? Not if North Carolina wants to follow 42 CFR 455.23 is its entirety.
42 CFR 455.23 also states:
Posted on March 14, 2013, in DHHS, Division of Medical Assistance, Federal Law, Health Care Providers and Services, Legal Analysis, Legislation, Medicaid, Medicaid Appeals, NCGS 108C-7, Prepayment Review and tagged Administrative Law Judge, Centers for Medicare and Medicaid Services, DHHS, DMA, Medicaid, North Carolina, Prepayment, Recovery Audit Contractor. Bookmark the permalink. Leave a comment.