Recent Order Stays DMA’s Withholding of Medicaid Reimbursements

Yes, these lawsuits actually can be won.

With the amount of North Carolina health care providers that accept Medicaid:

(1) undergoing prepayment reviews,

(2) suffering from withheld Medicaid reimbursements by the Managed Care Organizations (MCOs), Recoupment Auditing Companies (RACs), or the Division of Medical Assistance (DMA) (for the sake of simplicity, I will refer to any entity as DMA, since all companies are working at the direction of DMA), and

(3) barely making payroll because of the Medicaid reimbursements.

I wanted to shed a ray of hope for those health care providers.  (The same ray of hope applies to):

  • Prepayment Reviews
  • Tentative Notices of Overpayment
  • Termination of Medicaid Contracts
  • Rescissions of Medicaid contracts

The erroneous actions of DMA CAN be stopped!!!

All over North Carolina, health care providers are fighting the erroneous actions of DMA in order to keep the providers’ doors open for the Medicaid recipients.

An Order signed by an Administrative Law Judge (ALJ) at the Office of Administrative Hearings (OAH) a few months ago ORDERS DMA (the Respondent in this case) to STOP withholding Medicaid reimbursements.


NOW THEREFORE, based upon the forgoing findings of fact and conclusions of law it is hereby decided that the Respondent’s decision to suspend Petitioner’s Medicaid payments should be and is REVERSED.

This particular decision was drafted out of case # 12 DHR 02162.

All it takes is for the health care providers to stand up against DMA and prove that the Medicaid documents allegedly incorrect in the eyes of DMA are actually compliant. In other words, DMA’s withholding of Medicaid reimbursements is ERRONEOUS.

About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on March 22, 2013, in Division of Medical Assistance, Harassment, Health Care Providers and Services, Injunctions, Legal Analysis, Medicaid, Medicaid Appeals, Medicaid Audits, Medicaid Recoupment, North Carolina, OAH, Reconsideration Reviews, Termination of Medicaid Contract and tagged , , , , , . Bookmark the permalink. 2 Comments.

  1. I am just curious about something……. I know that a provider can not bring legal action directly against DMA because of their “sovereign immunity” ( which I disagree with ), but could a provider bring legal action against one of these audit firms ( PCG, etc..) for doing some of these horrible audits??

    • To everyone,

      A provider CAN bring an action against DMA. We’ve brought injunctions against DMA. We are also moving forward with a lawsuit involving multiple Plaintiffs against the MCOs and the State. Or against the RACs and the State. Action can be and should be taken.

Leave a Reply

%d bloggers like this: