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NCTracks Lawsuit Dismissed! Judge Finds Providers Failed to Exhaust Their Administrative Remedies!

Remember July 1, 2013? Providers across North Carolina probably still suffer PTSD at the mention of the “go-live” date for NCTracks.  If you remember July 1, 2013, you probably also remember that my former firm filed a class action lawsuit on behalf of the physicians in NC who suffered losses from NCTracks’ inception.

There was oral argument at the NC Business Court.

Judge McGuire, of the NC Business Court, dismissed the NCTracks class action lawsuit stating the providers failed to exhaust the administrative remedies.  The Order reads, in part:

“Ultimately, the burden of proving that administrative remedies are inadequate in this action rests on Plaintiffs.  Jackson, 131 N.C. App. at 186.  Although sympathetic to the apparently difficult administrative process, the Court concludes that, particularly in light of the fact that not a single Plaintiff has attempted to use the available administrative procedures to resolve their Medicaid reimbursement claims, Plaintiffs have simply failed to satisfy this burden.  Accordingly, Defendants’ Motions to Dismiss pursuant to Rule 12(b)(1) should be GRANTED.”

While I understand the logic applied to come to this decision, I do not necessarily agree with the outcome.  There are exceptions to the exhaustion of administrative remedies, which, in my humble opinion, are present here.

(This blog contains my own opinions as to the NCTracks ruling and not those of my present or former firms.  It is not intended to claim any ruling was incorrect or inconsistent with case law, rules, and statutes).

(Try to read the foregoing sentences in a fast-paced, tiny, whispery voice, like a pharmaceutical commercial).

Regardless, where does this decision leave the physicians in NC who suffered under an, admittedly, botched, beginning of NCTracks? (Even DHHS recognized the imperfections at the beginning).

First, what is the doctrine of failure of administrative remedies? (I was going to start with what is NCTracks, but you do not know what NCTracks is, you probably should begin reading some of my earlier blog posts: blog; and blog; and blog).

In a nutshell, the exhaustion doctrine dictates that if a party disagrees with an adverse action of a state agency that the party must exhaust its administrative remedies before asking for relief from a civil court judge.

What?

Law 101: The Office of Administrative Hearings (OAH) has limited jurisdiction. It only has jurisdiction over those matters specifically granted to it by statute. If you have an issue with a final adverse decision of a state agency, you sue at OAH. In other words, if you want to sue a state agency, such as DHHS, or any of its agents, like an MCO, you sue at OAH, not Superior Court.  An Administrative Law Judge, or ALJ, presides over the court.  While OAH is more informal than Superior Court, OAH follows the rules of civil procedure unless an administrative rule exists.

If a Superior Court were to find that the party failed to exhaust its administrative remedies, then the court would find that the party lacked subject matter jurisdiction; i.e., the court is holding that it does not have the authority to determine the legal question at issue.

You would be back to square one, and, potentially, miss an appeal deadline.

In the Medicaid world this is similar to a managed care organization (MCO) having an informal review process internally which would be required prior to bringing a Petition for Judicial Review at OAH.

Were you to bring a Petition for Judicial Review at OAH prior to attending an informal reconsideration review at the MCO, the ALJ would, most likely, dismiss the case for failure to exhaust your administrative remedies.

But in the NCTracks case, the Plaintiffs sued DHHS and Computer Science Corporation (CSC).  CSC is, arguably, not a state agency. The only way in which you could sue CSC at OAH would be for an ALJ to determine that CSC is an agent of a state agency.  And, who knows? Maybe CSC is an agent of DHHS.  Judge McGuire does not address this issue in his Order.

Many of you may wonder why I opine that CSC is not an agent of the state, yet surmise that the MCOs are agents of DHHS.  Here is my reasoning: DHHS, in order to bestow or delegate its powers of administering behavioral health to the MCOs, was required to request a Waiver from the federal government.  Unlike with CSC, DHHS merely contracted with CSC; no Waiver was required.  That Waiver (two Waivers, really, the 1915(b) and 1915(c)) allow the MCOs to step into the shoes of DHHS….to a degree…and only as far as was requested and approved by CMS…no more.  I view CSC as a contractor or vendor of DHHS, while the MCOs are limited agents.

Going back to NCTracks…

One can surmise that, because Judge McGuire dismissed the entire lawsuit and did not keep CSC as a party, Judge McGuire opined that CSC is an agent of DHHS.  But there is a possibility that the providers sue in OAH and an ALJ determines that OAH is not a proper venue for CSC.  Then what? Back to Superior Court and/or Business Court?

Why do you have to exhaust your administrative remedies? It does seem too burdensome to jump through all the hoops.

The rationale behind requiring parties to exhaust their administrative remedies is that those entities (such as OAH) that hear these specialized cases over and over and develop an expertise to decide the certain esoteric matters that arise under their jurisdiction. Also, the doctrine of separation of powers dictates that an agency created by Congress should be allowed to carry out its duties without undue interference from the judiciary.

For example, Judges Don Overby and Melissa Lassiter, ALJs at the NC OAH have, without question, presided over more Medicaid cases than any Superior Court Judge in the state (unless a Superior Court is a former ALJ, like Judge Beecher Gray).  The thinking is that, since Overby and Lassiter, or, ALJs, generally, have presided over more Medicaid cases than the average judge, that the ALJs have formed expertise in area.  Which is probably true.  It cannot be helped.  When you hear the same arguments over and over, you tend to research the answers and form an opinion.

So there is the “why,” what about the exceptions?

There are exceptions to the general rule of having to exhaust your administrative remedies that may or may not be present in the NC tracks case.  If you ask me, exceptions are present. If you ask Judge McGuire vis-à-vis his Order, there are no exceptions that were applicable.

One such exception to the general rule that you must exhaust your administrative remedies is if bringing a case at the informal administrative level would be futile.  If you can prove futility, then you are not required to exhaust your administrative remedies. Another exception is if you are requesting monetary damages that cannot be awarded at the administrative law level.

Where the administrative remedy is inadequate, a plaintiff is not required to exhaust that remedy before turning to the courts. Shell Island, 134 N.C. App. at 222. The burden of establishing the inadequacy of an administrative remedy is on the party asserting inadequacy. Huang v. N.C. State Univ., 107 N.C. App. 110, 115 (1992).

What DHHS argued, in order to have the case dismissed for lack of subject matter jurisdiction, and Judge McGuire agreed with, is:

that adequate administrative remedies exist for all health care providers when NCTracks improperly denies claims.

This holding is not without questions.

Some providers re-bill denied claims over and over.  There is a question as to when do you appeal?  The first denial? The second? The Fourteenth?  At which point do you accept the denial from NCTracks as a “final agency decision?”  Do you use the “3 strikes and you’re out” rule?  Do you give NCTracks a mulligan? Or do you wait until NCTracks “fouls out” with a 6th denial?

Another question that remains hanging in the wake of the NCTracks dismissal is how will providers handle the sheer volume of denials. Some providers receive voluminous denials.  Some RAs can be hundreds of pages long.

Let’s contemplate this argument in a hypothetical.  You run a nephrology practice.  The bulk of your patients are Medicaid (90% Medicaid, although 50% are dual eligible with Medicaid/Medicare). You have approximately 500-700 patients, who come see your doctors because they are in need of dialysis.  You know that if a person does not receive dialysis that there is a chance that the person can enter Stage 5 (end stage renal disease) and die quickly. However, upon July 1, 2013, when NCTracks went live, you stopped receiving Medicaid payments completely.  Do you stop accepting and treating your Medicaid patients? Obviously you do not stop accepting Medicaid patients?  But your practice cannot sustain itself.  Even if you continue to treat Medicaid patients, at some point, you will  be out of business, failing to meet payroll, and being forced to involuntarily not treat your patients.

Your patients in need of dialysis come to the office 3x per week.  A single hemodialysis treatment typically costs up to $500 or more — or, about $72,000 or more per year for the typical three treatments per week.

Let’s approximate with 500 patients.  500 patients multiplied by 3x per week is 1,500 per week. That is 1,500 denials per week.  What Judge McGuire is saying is that your office is burdened with appealing 1,500 denials per week.  Or 6,000 denials per  month. Or 72,000 appeals per year.

Which of your office staff will be charged with appealing at OAH 72,000 denials per year? The physicians?  You, the office manager (because you obviously have nothing else to do)?  The receptionist? Hire someone new?  For how much?  How will you recoup the cost of appealing 72,000 denials per year?  How many hours does it cost to appeal one?  Hire an attorney?

Obviously, my example is one of an extreme case with 100% denials. But the sentiment holds true even for 30%, 40%, or 50% of denials. The sheer volume would be overwhelming.

And you can imagine the backlog that would be created at OAH.

Judge McGuire’s decision that plaintiffs failed to exhaust their administrative remedies issue appears to be based, in part, that because no plaintiff had tried to go to OAH, plaintiffs could not convince him that the administrative remedy was non-functional.

“Significantly, none of the Plaintiffs even attempted to use the administrative procedures to address the failure to pay claims and other issues they allegedly encountered in attempting to use NCTracks. Instead, Plaintiffs allege that the administrative process would have been futile and inadequate to provide the relief they seek.”  See Abrons Family Practice v. DHHS and CSC, ¶ 36 (emphasis added).

What now?

Well, first of all, when I moved to Gordon & Rees, I left this case in the capable hands of my former partners, so I have no special intelligence, but I wager that this is not the end.

There are choices. They could:

(1) Appeal the decision to the Court of Appeals;

(2) File an insurmountable number of petition’s at OAH; or

(3) Do nothing.

For some reason, I have my doubts that #3 will occur.

What do you think???  What should the Plaintiffs do now in the wake of this dismissal?

The NC MCOs: Jurisdiction Issues and Possible Unenforceable Contract Clauses with Medicaid Providers

According to NC Superior Court, OAH (and I) has (have) been right all along…OAH does have jurisdiction over the MCOs.  And you cannot contract away protections allowable by statute.

Before I went to law school, I do not recall ever thinking about the word “jurisdiction.”  Maybe in an episode of Law and Order I would hear the word thrown around, but I certainly was not well-versed in its meaning. While I was in law school, the word “jurisdiction” cropped up incessantly.

“Jurisdiction” is extremely important to North Carolina Medicaid providers.  Jurisdiction, in the most basic terms, means in which court to bring the lawsuit or appeal of an adverse determination.

In this blog, I am mostly referring to terminations/refusals to contract with providers by the managed care organizations (MCOs), which manage behavioral health, developmental disability, and substance abuse services for North Carolina. Recently, there have been a slew of providers terminated or told that they would not receive a renewed contract to provide Medicaid services. The MCOs tell the providers that, per contract, the providers have no rights to continued participation in the Medicaid system.

The MCOs also tell the providers that the providers cannot appeal at OAH… That the providers have no recourse… That the providers’ contracts are terminable at will (at the MCO’s will)…. I have been arguing all along that this is simply not true. And now a Superior Court decision sides with me.

The MCO have been arguing in every case that OAH does not have jurisdiction over the actions of the MCOs.  The MCOs have pointed to NC Gen. Stat. 108D and Session Law 2013-397, which amends NC Gen. Stat. 150B-23 to read:

“Solely and only for the purposes of contested cases commenced as Medicaid managed care enrollee appeals under Chapter 108D of the General Statutes, a LME/MCO is considered an agency as defined in G.S. 150B-2(1a). The LME/MCO shall not be considered an agency for any other purpose.”

A termination or denial to participate in the Medicaid program is an adverse determination. Adverse determination is defined in NC Gen. Stat. 108C-2 as, “A final decision by the Department to deny, terminate, suspend, reduce, or recoup a Medicaid payment or to deny, terminate, or suspend a provider’s or applicant’s participation in the Medical Assistance Program.”

The Department is defined as, “The North Carolina Department of Health and Human Services, its legally authorized agents, contractors, or vendors who acting within the scope of their authorized activities, assess, authorize, manage, review, audit, monitor, or provide services pursuant to Title XIX or XXI of the Social Security Act, the North Carolina State Plan of Medical Assistance, the North Carolina State Plan of the Health Insurance Program for Children, or any waivers of the federal Medicaid Act granted by the United States Department of Health and Human Services.”

Obviously, per statute, any entity that is acting on behalf of DHHS would be considered the “Department.” Any adverse act by any entity acting on behalf of DHHS, including terminating a provider’s participation in the Medical Assistance Program is considered an adverse determination.

The MCOs have been arguing that the above-referenced amendment to 150B means that the MCOs are not agents of the state; therefore, OAH has no jurisdiction over them.

Until March 7, 2014, these issues have been argued within OAH and no Superior Court judge had ruled on the issue.  Most of the Administrative Law Judges (ALJ), even without Superior Court’s guidance, has, in my opinion, correctly concluded that OAH does have jurisdiction over the MCOs.  A couple of the ALJs vacillate, but without clear guidance, it is to be expected.

On or about March 7, 2014, the Honorable Donald W. Stephens, Senior Resident Superior Court Judge ruled that OAH does have jurisdiction over the MCOsYelverton’s Enrichment Services, Inc. v. PBH, as legally authorized contractor of and agent for NC Department of Health and Human Services (DHHS).

If these MCOs are acting on DHHS’ behalf in managing the behavioral health Medicaid services, it would be illogical for OAH to NOT have jurisdiction over the MCOs.

In the Yelverton Order, Judge Stephens writes, “OAH did not err or exceed its statutory authority in determining that it had jurisdiction over Yelverton’s contested case.”

The Order also states that the MCO, in this case, PBH (now Cardinal Innovations), agreed that only DHHS had the authority to terminate provider enrollment. The MCO argued that, while only DHHS can terminate provider enrollment, the MCOs do have the authority “to terminate the participation of the provider in the Medical Assistance Program.”

Talk about splitting hairs! DHHS can terminate the enrollment, but the MCO can terminate the participation? If you cannot participate, what is the point of your enrollment?

Judge Stephens did not buy the MCO’s argument.

On March 7, 2014, Judge Stephens upheld ALJ Donald Overby’s Decision that OAH has jurisdiction over the MCOs for terminating provider contracts.

I anticipate that the MCOs will argue in future cases that the Yelverton case was filed prior to Session Law 2013-397, so Yelverton does not apply to post-Session Law 2013-397 fillings. However, I find this argument also without merit. The Yelverton Order expressly contemplates NC Gen. Stat. 108D and House Bill 320.

House Bill 320 was the bill contemplated by the General Assembly in the last legislative session that expressly stated that OAH does not have jurisdiction over the MCOs. It did not pass.

In Yelverton, the MCO argued that the MCO contracts with the providers allow the MCO to terminate without cause and without providing a reason.

Judge Stephens notes that the General Assembly did not pass House Bill 320. The Yelverton Order further states that no matter what the contracts between the providers and the MCOs states, “[c]ontract provisions cannot override or negate the protections provided under North Carolina law, specifically appeal rights set forth in NC Gen. Stat. 108C.”

Will the MCO appeal? That is the million dollar question…

Final Agency Decision No Longer Needed in Medicaid Appeals

This is huge!! Not often in Medicaid administrative law, does the appeal process actually change.  But the appeal process has changed.

In the past, to appeal a decision from North Carolina Department of Health and Human Services (DHHS), you had to file a Petition for Contested Case. The Petition would be heard by an Administrative Law Judge (ALJ) at the Office of Administrative Hearings (OAH).

Once the ALJ rendered a Decision, DHHS would review the ALJ Decision and render a “Final Agency Decision.” Since DHHS is the entity rendering the Final Agency Decision, 9 times out of 10, the Final Agency Decision happened to decide in favor of the Department.

To appeal a Final Agency Decision, you had to request a Judicial Review in Superior Court.  For the Judicial Review,  the Superior Court sits as a Court of Appeals.  Meaning no additional testimony or evidence may be introduced, but each side arguments the legal arguments with the evidence already introduced at OAH.

Not anymore. For dental, behavioral health, and medical authorizations, following an OAH Decision, no Final Agency Decision will be rendered.

This means that any decision made by OAH is the decision that the provider and beneficiary can act upon and that a final agency decision by DHHS is no longer required. 

OAH will mail a copy of the decision via trackable mail (e.g., certified mail, registered mail, USPS trackable mail) to the parties identified on the appeal request form.

How the OAH decision is implemented depends on whether the Decision agreed with DHHS (or the contracting company) or overturned DHHS, in full or in part.  The implementation language is no important, I copied and pasted the language from the http://www.ncdhhs.gov/dma/bulletin/0313bulletin.htmhttp://www.ncdhhs.gov/dma/bulletin/0313bulletin.htm.

See below:

An OAH decision that upholds the agency action will be implemented no later than three business days from the date the OAH hearing decision is mailed.

Decisions that Reverse the Agency Action (Utilization Review [UR] Contractor Decision) in Part or in Full

  • If the OAH decision or a mediated settlement holds that all or part of the requested services were medically necessary, payment for those services as approved in the OAH decision or settlement will be authorized by Medicaid or its UR contractor within three business days of receipt of the decision. This authorization will remain in effect for 20 prospective calendar days after the date of the decision.
  • If the provider believes that it is medically necessary for the beneficiary to continue the service that has been under appeal, the provider shall submit a prior approval request to the appropriate UR contractor within 15 calendar days of the date of the OAH decision in order to avoid an interruption in services. Upon receipt by the UR contractor of a request for service authorization within the 15 calendar days of the OAH decision, a determination to approve, deny, reduce, or terminate the request will be made within 15 business days – or in accordance with the contractor’s contract with Medicaid. If the request cannot be approved as submitted, authorization for payment will remain in effect without interruption for at least 10 calendar days following the mailing of the notice of decision on the new request for prior approval.
  • If the request is denied or reduced, it will be treated as a timely request for reauthorization and maintenance of service (MOS) pending appeal will apply.

Remember, regardless of the OAH Decision, you still have the right to a judicial review at Superior Court.