Jeyaram & Associates - Client Advisory

Five Things Every Medicaid Provider Should Know

By DJ Jeyaram

Provider Manuals Are Always Changing

At current count, the Georgia Department of Community Health (“DCH”) has 80 different provider manuals and schedules. The provider manuals are continually being revised to clarify and update various provisions.

You should regularly review those manuals that are applicable to your categories of service and review them for changes. Don’t worry—you probably won’t need to read the entire manual again, as DCH typically includes revision dates next to each section that has changed.

However, it is important to note that when DCH changes a manual provision, it does not mean that the change is legal. The manuals are DCH’s contract with providers. Therefore, changes must comply with most provisions of basic contract law as well as with governing state and federal laws and regulations; any of which can render a conflicting manual provision invalid.

Preserve Your Rights

The DCH appeals process allows for an “administrative review” where DCH can review a matter, with additional documents and information submitted by the provider, in an attempt to resolve issues before hearing. But be careful!

An administrative review is still part of the appeals process and if you are not careful, you can severely hinder your chances of success if the matter proceeds to hearing. If you choose to proceed without legal counsel, be aware that anything said in any correspondence with the DCH can be treated as an admission and used at a hearing.

Even a simple statement such as “I’m sorry this was late” can cost the provider the case—EVEN IF THE DOCUMENT WAS NOT LATE IN THE FIRST PLACE! DCH can take the provider’s “admission” that the document was late and file a motion with the Administrative Law Judge and the case could be disposed of on those grounds.

Comply With Deadlines

When filing requests for administrative review or hearing, be careful to comply with all deadlines. If a request is beyond the time-frames set forth in the provider manual, DCH will likely not even look at the merits of your case.

DCH is short staffed and when given an easy and legitimate way to dispose of a case, DCH will likely make use of it. If you need more time to gather documents or consult with staff before responding to DCH, request an extension in writing before the original deadline has elapsed.

DCH May Disagree With Third-Party Contractors

When you are faced with a proposed Adverse Action from DCH, ask to see the work documents underlying that decision and review them with the decision maker at DCH. If the proposed action is based on work done by a DCH third-party contractor, including other state agencies, many times on closer review DCH will disagree with the third-party contractor’s conclusions and may even reverse its decision.

Win Your Case At Hearing

If your case is not resolved on administrative review, it will be important to present a
strong case at the administrative hearing. Any appeal from the administrative hearing is sent to the Commissioner of DCH, who almost never rules against his or her own agency.

The case is then appealed to Superior Court. The standard of review in Superior Court gives great deference to the administrative judge’s rulings. So preparing a strong case early in the DCH appeals process is essential to a successful outcome.

For questions or comments about this article please contact the author, D.J. Jeyaram, at 404.995.6792 or dj@jeylaw.com.

This article is presented for educational and informational purposes only and is not intended to constitute legal advice.

About the Author

Deepak (“D.J.”) Jeyaram is the founder of Jeyaram & Associates, a full service health law firm. He represents a wide variety of healthcare providers including hospitals, nursing homes and physician group practices. He concentrates his practice in healthcare regulatory matters, primarily in administrative appeals and Medicare and Medicaid reimbursement.

His prior experience includes working in-house with Georgia Medicaid, rising to the position of Deputy Director of Legal Services. Later in his career, Jeyaram was an Administrative Law Judge who presided over disputes between the Georgia Department of Community Health and Medicaid providers on issues involving reimbursement, utilization review and provider termination. Jeyaram received his bachelor’s degree, cum laude, from Boston University and his law degree from Emory University.

Jeyaram & Associates is conveniently located in the heart of Buckhead in the Pinnacle building next to Lenox Mall. For a map of the office location, please click here.

For a free consultation, call DJ Jeyaram at 404.995.6792 or send an email to dj@jeylaw.com.