SB 553: Read the Plain Language of the Statute….Or…”Do You Understand the Words That Are Coming Out of My Mouth?”
One of my pet peeves is when people park in handicapped parking spots (especially at the grocery store…because, of course, they are just running in for one thing) without a handicapped sticker or any physical ailment. The handicapped spot is meant to be used by a person with a handicap, not the person in a hurry. Or when the person in the grocery store has 14 items, yet still stands in the “10 items or less line.” “10 items or less” means “10 items or less!!” There is a reason for the theory behind “10 items or less.” When people exploit the “10 items or less” aisle that were not intended to benefit from “10 items or less,” the very purpose of the “10 items or less line” is thwarted.
“Do you understand the words that are coming out of my mouth?”
Similarly, in law school, you learn to read statutes with what is called “The Plain Meaning Rule.” The Plain Meaning Rule means that if the statutory language is clear on its face (prima facie) and there is no reasonable doubt as to its meaning, then the judge will simply apply the language of the statute to the case at hand.
As in, if the sign says “10 items or less,” do not stand in line with 14 items.
This week I have 5 hearings. (I know…ugh, right?! Good thing I love my job and believe in my cause). Well, it is Tuesday. So far in two of my hearings, opposing counsel representing the managed care organizations (MCOs) have argued that SB 553 applies to providers and holds that providers cannot appeal grievances to the Office of Administrative Hearings (OAH). And that OAH has no jurisdiction over the MCOs for these appeals.
Ok, seriously, you are probably reading this thinking…what the heck is Knicole talking about….usually I understand her rants…but what is SB 553 and why is she arguing that it does not apply to providers….
SB 553, or Session Law 2013-397 states, in pertinent part, “Right to LME/MCO Level Appeal. – There is no right to appeal the resolution of a grievance to OAH or any other forum.”
No right to appeal to OAH?? Or any other forum?? Basically, you must appeal within the MCO…you must exhaust all administrative remedies prior to appealing to OAH.
What venue does “no-OAH-or-any-other-forum” leave? Reading the plain language of SB 553, you have a right to an MCO level appeal…nothing else (until you exhaust the appeal at the MCO). Yet, per common sense, if an MCO makes a decision with which you do not agree, and you appeal to the very people who made the adverse decision, the “reconsidered decision,” more times than not, will be identical to the original adverse decision.
So for SB 553 to mandate that no right to appeal a grievance at OAH is HUGE!! And I would argue that SB 553 takes away a right to appeal at OAH that is (a) embedded with the OAH Mission Statement; and (b) found with NC General Statutes 150B.
But to whom does SB 553 apply?
The MCOs in the last 2 days have argued that SB 553 applies to Medicaid provider. So to whom does SB 553 apply???
Remember the “Plain Meaning Rule?” Let’s look at the plain language of the Session Law. Let’s start with the title. The title of Part 1of SB 553 (the part at issue) is:
PART I. ESTABLISH GRIEVANCE AND APPEAL PROCEDURES FOR LOCAL MANAGEMENT ENTITY/MANAGED CARE ORGANIZATION MEDICAID ENROLLEES.
The title does NOT say “Medicaid enrollees and Medicaid providers.” Nope. Enrollees. Period.
Further, enrollee is defined as:
Enrollee. – A Medicaid beneficiary who is currently enrolled with a local management entity/managed care organization.
If the title states that it applies to “Medicaid enrollees,” then, per the title, the Session Law does NOT apply to Medicaid providers (unless they are appealing on behalf of a Medicaid recipient…standing in the shoes of the Medicaid recipient).
If the sign says “10 items or less,” it means “10 items or less.” Simply count the number of items in your grocery cart. If the items equal to less than or equal to 10, go to the “10 items or less line.” If the items in your cart equal greater than 10, do not stand in the “10 items or less line.”
Do you understand the words coming out of my mouth???!!!
Posted on September 24, 2013, in Division of Medical Assistance, Health Care Providers and Services, Legal Analysis, Legislation, MCO, Medicaid, Medicaid Appeals, NC DHHS, North Carolina, OAH, Office of Administrative Hearings, Petitions for Contested Cases and tagged Administrative Law Judge, Division of Medical Assistance, Health care, Health care provider, Managed care, Managed Care Organizations, MCO, Medicaid Services, NC DHHS, NC Medicaid, North Carolina, North Carolina Department of Health and Human Services, Senate Bill 553, Session Law 2013-397. Bookmark the permalink. 3 Comments.