Tuesday, October 14, 2008

New Medicaid services appeal for Medicaid consumers: everything has moved to OAH as of 10.1.2008:but WHERE IS V.O. IN THE MIX?

There's a very slick sleight of hand being outlined here. Listen carefully:

The law offices associated w/ Douglas Sea, in Charlotte, NC, is interested in obtaining information about Medicaid appeal complexities as associated with MOS matters e.g., diminishment of services w/o client being able to appeal the matter.

Indeed, Mr. Sea's office was instrumental in guiding an Endorsed Provider company in western NC as associated with information pertaining to the OLDER, ORIGINAL MOS----rather than the newer MOS.

Why would there be two sets of authorization requests for CSS? As in the case of the clients' cases described here, many Endorsed Provider companies crashed as NC DHHS diminished CSS hours. They were left in the place of having delivered the services and paying their employees but then were gigged by NC DHHS as associated with paperwork problems and then demanded to payback to NC Medicaid. They simply went under.

HOWEVER, the original appeal made by the crashed company, linked to the request for services, WERE STILL IN EFFECT. THIS is what Mr. Sea's office has been able to highlight re: reduction in CSS which has never moved thru the informal appeal/ mediation/ formal appeal process.

So, NC DHHS set into motion events that they then not legally deal w/ re: the legal demand that a reduction in Medicaid services have a process----which was never gotten to----re: the avalanche of appeals.

He can be reached at: "Douglas Sea" . I am told that a class action lawsuit is in development.

Website for Legal Services of Southern Piedmont:


Douglas Sea, Attorney and Senior Program Director
Dorothée Alsentzer, Attorney
Robert Davis, Attorney
Ellen Hamilton, Paralegal Advocate
Alison Hartman, Paralegal Advocate


Informal Medicaid service appeals ended September 30. No informal hearings were held after that date (although some decisions may have been issued on hearings held before October. Anyone with informal appeal still waiting for a hearing as of Oct 1 was supposed to be informed of option to have case transferred to OAH. DMA still has put nothing on its website yet about the changes and has issued no written info to providers that I have seen. I have three questions for all of you:

1) Do you have or know of any clients with pending informal appeals where hearing was not held by September 30? If so, has your client received a notice about transferring the case? If so, what does the notice say? Please fax it to me after marking out client identifying info. Be aware of a possible 30 day deadline for client to respond in writing to that notice.

2) Do you have or know of any clients who received a notice of denial or termination of Medicaid services since September 19? If so, did that notice include informal appeal rights or only formal appeal rights? Please fax it to me, again after removing client info.

3) If your client got a notice including informal appeal rights recently and tried to request an informal appeal on or after 10/1, what happened to that appeal? What was client told?

AGAIN, CONTACT HIM HERE: dougs@lssp.org


Legislatively created back in June, 2008, by the NC State Legislature, as associated with an avalanche of CSS Medicaid appeals as NC DHHS cut Community Support Services (CSS), the Office of Administrative Hearing (OAH), is now handling Medicaid appeals. Paperwork associated with this matter appears to be the key H-06. The form is here:

(cut and paste):

NC DHHS scrambled to have hearings on denial of Community Support Services prior to the October 1, 2008 deadline as evidenced by telephoning Endorsed Provider company representatives in order to set up a time for informal appeals for their Medicaid clients who had commonly been denied CSS, prior to even the delivery of letter to the Endorsed Provider company representatives. In some cases, the clients never have received any paperwork about their informal hearings from NC DHHS.

In that Value Options (VO) is the authorizing agent for Medicaid Services for NC DHHS, how is VO going to tackle this matter of the interfacing of OAH w/ DHHS? Can we expect more of the same lack of timely f/u as re: VO?

And to whom will these problems be reported? To NC DHHS?----who has been allowed to wash its hands of the appeals matter re: their inability to deal w/ the avalanche of Medicaid denials associated w/ NC DHHS diminishing CSS hours----or the Office of Administrative Hearing----who has no interest in mental health matters and/ or the delivery of services other than to deal w/ the informal appeals/ mediation/ formal appeals of the denial of services?

It seems to me that once again we have 'progressed' to the place of no-one-knows-what-to-do-because-they-are-not-the-responsible-party which has become a well honed skill in NC mental health reform.


Here is the outline of a telephone conversation w/ personnel at Office of Administrative Hearing.

Telephone conversation 10.14.2008 2 pm, approx:


DHHS Hearing Office, Yvette Young, indicated that DHHS is in the process of forwarding informal appeal documents to OAH.

Laura Brown, Supervisor on the Administrative side of Hearings (this is how she stated her title is: 919 855 4260), referred the caller to Jane Plaskie.

Jane Plaskie, Appeals Coordinator, Clinical Policy within DMA: 919 855 4260

She stated: the General Assembly passed into law on July 1, 2008, that informal appeals thru the DHHS Hearing office would no longer be available to recipients, effective October 1, 2008. From that date all appeals would go to the Office of Administrative Hearing. Ultimately, clients could have a formal hearing in front of a judge at various locations around the state.

Before the judge’s decision, they would be offered the opportunity for mediation involving DMA staff, the vendor that made the decision e.g., Value Options, and the recipient. At that point, the recipient could accept the mediated offer or elect to still go before the judge.

Plaskie stated that MOS still applies. This means that the client can continue with the ORIGINALLY obtained services (for instance, more than the 8 hours/ week/ client/ CSS) until the matter is settled.


That sounds organized, right? NC DHHS has called the Endorsed Provider companies to let them know of the possibility of taking care of the Medicaid appeals prior to the matter being forwarded, as was legislatively determined, to the OAH.

PRIOR TO this legislatively determined matter, there were 11 days (now 30 days under OAH) to make an appeal about the reduction of services.

Over the past year or so, as CSS have been denied and severely diminished, when Medicaid appeals were made to NC DHHS, it was not uncommon for NC DHHS to have the NEWER Medicaid appeals paperwork----put together by the newer, non-crashed Endorsed Provider company who took over the clients from the crashed company----before them---but not OLDER appeals paperwork created by the crashed Endorsed Provider company.

So, unless the newer Endorsed Provider company realizes it, the non-challenged, never having moved fully thru the appeals process consisting of: informal/ mediation/ formal before a judge---appeals (in that order) MOS remains in effect IF the reduction in services was appealed to begin with----as CSS were being defunded and diminished.

REMEMBER to figure out WHEN the original appeal to NC DHHS was created. THAT will determine the services that are currently in place as associated with a continuation of MOS until the appeals process moves its way thru the OAH system.

However long that takes.


Post a Comment

<< Home