What is the “law” of North Carolina Medicaid? I mean, as a health care provider in North Carolina accepting Medicaid, you are expected to know EVERYTHING.  You must follow ALL laws/regulations/policies to a tee. Yet you have:

1.  The State; i.e., the  Division of Medical Assistance (DMA);

2.  The Managed Care Organizations (MCOs); i.e.; Alliance Behavioral Health (Alliance), Cardinal Innovations (Cardinal), East Carolina Behavioral Health (East Carolina), or whatever MCO is in charge of your county; not to mention,

3.  The Recovery Audit Contractors (RACs); i.e., Carolinas Center of Medical Excellence (CCME), Public Consulting Group (PCG), and HP Enterprises (HP);

all telling you that you are NOT following the (fill in the blank) (a) the law; (b) NC Medicaid rules and regulations; (c) the DMA Clinical Policies; (d) the Implementation Updates; (d) the Basic Medicaid Billing Guide; or (e) all of the above.

Let’s break it down.

First, in the world of Medicaid, because federal dollars are used, the federal law is supreme.

Therefore, if any state, whether North Carolina or Alaska, states that you must abide by “_____” and “_____” is specifically not allowed by federal law, “_____” violates federal law and is not “law.” So many people just assume that if North Carolina states “____”…”____”  must be “law.”  Forgive me for being the naysayer, but the U.S. federal government is supreme.  As in, if North Carolina and the U.S. government got in a fight, NC would be the underdog. Yet, despite the fact, most people read a NC general statute and act as a Stepford Wife….”Yes,  sir, it must be true.”

So let’s put the Medicaid laws in a hierarchy, most important to least important:

1. Federal law.  Most of the federal Medicaid regulations are found in the Code of Federal Regulations (CFR). (Please understand that this blog is NOT comprehensive; I am merely trying to simplify a system that is not easily simplified.  Please contact an attorney if you have any questions (not necessarily me:) ).  There is also the Social Security Act.

2.  Centers for Medicare and Medicaid Services (CMS).  I know, CMS is a federal agency. Why would I denote CMS as the second most important in the genre of Medicaid law? CMS does not make law.  CMS must follow federal law.  But, in reality, let me assure you, if CMS says its ok, it is ok.  So it is important to note CMS.

CMS issues guidance in the form of letters to State Medicaid Directors and letters to State Health Officials. CMS also issues federal regulations. Issue. Not draft. Regardless, CMS is important.

3.  North Carolina laws.  Here’s where it gets sticky…

People make good money on arguing as to which NC laws/policies/manuals are most important.

In my humble opinion, only promulgated policies are mandatory.

What does promulgated mean?

Definition of PROMULGATE