Because I do make every effort to assure the information I disseminate for families and other interested parties / agencies is factually acurate, I followed up with the good folks over at DRNC regarding the preceding post, Appeals & Due Process (or Lack There Of), so see if there had been any changes since my last missive was sent and posted which included due process concerns...
Below is the response I received:
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From: Jennifer Bills
Sent: Friday, August 24, 2012 11:37 AM
The post is not inaccurate, especially if you read to the end about the status of Final Agency decision-making; however, Elizabeth and I consulted and feel that the tone is far too pessimistic.
Our response post would be:
Document, Document, Document
Medicaid recipients have a decent track record, both when they are represented by counsel but also pro se, of prevailing in Medicaid appeals. The key is to obtain and provide adequate documentation of the medical necessity of the service, and specific details regarding the amount of hours the individual needs. Understanding the criteria used to evaluate requests for services is particularly important. Decisions can only be based on sufficient evidence of the precise amount and type of Medicaid service that is medically necessary for the individual. Appeals should focus on the individual’s medical and social needs, as opposed to the family’s needs, even when families are providing the care. Although hardships to a recipient’s natural supports may provide context for an appeal, that alone may not meet the criteria in the service definition. Letters from clinicians, social workers, direct care staff, case managers or community guides, and families are essential to justify services. Additionally, documentation from medical providers, or a log of behaviors created by the family or direct care staff, may be more persuasive than testimony based on recollection or memory.
Even at the Reconsideration stage, if you provide additional information supporting the request, there is a chance of getting a different decision. Although OAH is not yet making the final decisions, the State legislature directed DHHS to submit a request to CMS to grant OAH this authority, and that process is ongoing. Many cases settle during the appeals process, and cases rarely go all the way to Superior Court. OAH rules allow mediators and judges to assist pro se clients with navigating the appeals process. Although they are neutral and not advocates, they help ensure the process is fair. Our message would be: don’t give up on due process. Rather, utilize it and win!
And it would be great if she could add a link to our MCO Medicaid Appeals fact sheet, attached here.
Jennifer Bills, Senior Attorney
Disability Rights North Carolina
Champions for Equality and Justice
Disability Rights NC is the state's protection and advocacy system. DRNC is a 501 (c)(3) organization. If you are a state government employee, you can support Disability Rights North Carolina through the State Employees Combined Campaign (SECC). Please use code # 1544. Donations support our efforts to promote a clear and independent voice for North Carolinians with disabilities.
