Another Win! 12 Million Dollar Recoupment Reduced to $896 – But There is a Twist
One of our clients in New Mexico had an alleged Medicaid recoupment of over $12 million!! Actually, $12,015,850.00 – to be exact. (See below). After we presented our evidence and testimony, the Judge found that we owe $896.35. I call that a win!
In this case, the Human Services Department (HSD) in New Mexico had reviewed 150 random claims. Initially, HSD claimed that 41 claims out of 150 were noncompliant.
But, prior to the hearing, we saved over $10 million by pointing out HSD’s errors and/or by providing additional documentation.
And then the ALJ’s decision after we presented our evidence and testimony –
Boom! Drop the mike…
…………………………….not so fast…
……………………………………………..picking the mike back up…
You see, in New Mexico, the administrative law judges (ALJs) cannot render decisions. Look in the above picture. You see where it reads, “Recommendation?” That is because the ALJs in New Mexico can only render recommendations.
Because Medicaid has a “single state agency” rule; i.e., that only one agency may render discretionary decisions regarding Medicaid, and HSD is the single state agency in New Mexico charged with managing Medicaid, only HSD may render a discretionary decision. So in NM, the ALJ makes a recommendation and then the Secretary of HSD has the choice to either accept or reject the decision.
Guess whether HSD accepted or rejected the ALJ’s recommendation?
Now we will have to appeal the Agency’s Decision to overturn the ALJ recommendation.
Here, in NC, we obtained a waiver from the Centers of Medicare and Medicaid Services (CMS) to allow our ALJs to render Decisions. See blog.
I still consider this a win.
Posted on November 9, 2016, in "Single State Agency", Administrative code, Administrative Law Judge, Administrative Remedies, Agency, Alleged Overpayment, Appeal Rights, Behavioral health, CMS, Due process, Extrapolations, Federal Government, Federal Law, Health Care Providers and Services, Knicole Emanuel, Lawsuit, Legal Analysis, Legal Remedies for Medicaid Providers, Medicaid, Medicaid Appeals, Medicaid Attorney, Medicaid Funds, Medicaid Providers, Medicaid Recoupment, Medicaid Reimbursements, Medicaid Services, NC, NC DHHS, New Mexico, North Carolina, Office of Administrative Hearings, Provider Appeals of Adverse Decisions for Medicare and Medicaid and tagged Administrative Law Judge, Agency decision, ALJ recommendation, Alleged Overpayments, Appeals of recoupments, Behavioral health, behavioral health care provider, Centers for Medicare and Medicaid Services, CMS, Fair Hearing Bureau, HSD, Human Services Department, Medicaid, Medicaid Recoupment, New Mexico, New Mexico Behavioral Health Providers, PCG, Personal, Post-Payment Review, Public Consulting Group, Secretary of Department of Health and Human Services, Single state agency, Waiver. Bookmark the permalink. 3 Comments.