Join the American Health Lawyers Association in Baltimore for the Institute on Medicare and Medicaid Payment Issues. Parker Poe’s Matt Wolfe will be providing an overview of ACA-Related Litigation and Impact of New Administration at a joint luncheon sponsored by AHLA’s Behavioral Health Task Force and AHLA’s Health Care Reform Task Force on March 30.
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The legal landscape for False Claim Act (“FCA”) cases recently shifted when the United States Supreme Court announced its decision in Universal Health Services, Inc. v. U.S. ex rel Escobar, No. 15-7, 2016 WL 3317565 (U.S. June 16, 2016) (“Escobar”). Whistleblowers (also known as relators) and health care providers alike have been eagerly awaiting this decision. Although each side hoped for a bright-line ruling, what they got was something of a mixed bag. In Escobar, the Court resolved a split in the U.S. Circuit Courts of Appeals over the application of the “implied certification theory” of False Claims Act liability.Read More
When the North Carolina Division of Medical Assistance (“DMA”) decides to place a Medicaid provider on prepayment review, it can be the equivalent of a death sentence for a small business. The primary problem is that there are few avenues to appeal the decision to be placed on prepayment review, even when there is little or even no justification for DMA’s decision. Prepayment review then becomes a waiting game reducing cash flow and overwhelming providers with a paper chase gotcha game. Although the initial decision to place a provider on prepayment review cannot be challenged, this does not mean that a Medicaid provider has no options to challenge the prepayment review process.
In May 2014, the American Hospital Association filed suit against the United States Department of Health and Human Services seeking to compel Administrative Law Judges (ALJs) to comply with applicable statutory deadlines for deciding Medicare claim appeals.
By law, ALJs are required to render a decision within ninety days of a request for hearing to appeal the second-level reconsideration determination (in the case of claims appeals) and the first-level reconsideration determination (in the case of entitlement appeals). ALJs are currently not in compliance with this requirement. The backlog of appeals is significant. The number of appeals made to the ALJ increased by over 500% from the 2011 fiscal year to the 2013 fiscal year, largely driven by the appeal of determinations by Recovery Audit Contractors. The number of appeals outstanding in July 2014 was 800,000. While both the Office of Medicare Hearings and Appeals and the Centers for Medicare and Medicaid Services have implemented a number of projects and pilot programs to try to reduce the number of appeals currently before the ALJ, many providers expect to wait years for an ALJ hearing.
In December 2014, the United States District Court for the District of Columbia determined that the delay did not warrant judicial intervention and granted a motion to dismiss the lawsuit. In a letter published in response to the decision, the AHA announced its intent to appeal the decision.
Contested cases heard at the North Carolina Office of Administrative Hearings (“OAH”), that result in a final agency decision are subject to appeal under a process called “judicial review.” In most cases, these appeals are filed in Superior Court. N.C. Gen. Stat. § 150B-145 mandates that a petition for judicial review of an Administrative Law Judge’s (“ALJ”) final decision must be filed in the Superior Court in the county where the “person aggrieved by the administrative decision resides.”
In 2011, the General Assembly determined that an agency can now file petitions for judicial review in the Superior Court appealing the final decision of an ALJ. When an Agency is appealing a final decision of an ALJ, a question has arisen regarding where the Agency should file its appeal – in Wake County or in the county where the provider resides?
A recent decision by the Wake County Superior Court concluded that, when the State agency files a petition for judicial review, it must file its petition in the county where the provider is located since under the APA a “person aggrieved” by the administrative decision is defined to be the provider challenging the agency’s decision and not the Agency. (Click here to view)
If you have recently prevailed in a contested case against an Agency and the Agency filed or is planning to file a petition for judicial review, your counsel should be aware that if the Agency files the petition in the wrong county, you may be able to have the appeal dismissed before having to spend exorbitant fees fighting the underlying challenge made by the agency.