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Leveling the Medicaid/Provider playing field

Asserting your rights and living to fight another day . Leveling the Medicaid/Provider playing field. James M. Barclay Healthcare attorney. Today’s session. Factors in deciding what to do next Action deadlines Provider options Using outside influence

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Leveling the Medicaid/Provider playing field

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  1. Asserting your rights and living to fight another day Leveling the Medicaid/Provider playing field James M. Barclay Healthcare attorney 850-591-4875 jmbarclay@comcast.net

  2. Today’s session Factors in deciding what to do next Action deadlines Provider options Using outside influence Steps in a formal administrative hearing Session take-aways 850-591-4875 jmbarclay@comcast.net

  3. Selected factors to consider in deciding what to do next • Regulation will continue • State agency will return • State has unlimited manpower and financial resources • Financial and licensure renewal threats of present matter • Cost-benefit of mounting a defense • Establishing/maintaining provider credibility • Withholding of Medicaid payments • Most cases settle • Termination from Medicaid 850-591-4875 jmbarclay@comcast.net

  4. Deadlines for action Involve competent counsel at outset Agency action in writing Notice of Intent to Deny Final Audit Letter Information about administrative hearing rights Usually 21 days from receipt Election of Rights Form 850-591-4875 jmbarclay@comcast.net

  5. Provider options Do nothing Informal administrative hearing Formal administrative hearing Rule challenge/challenge to agency statement 850-591-4875 jmbarclay@comcast.net

  6. Option 1 – do nothing Agency will enter Final Order by default for relief requested Minimal fees Matter kept below radar 850-591-4875 jmbarclay@comcast.net

  7. Option 2 – timely request informal hearing Usually favors the Agency Agency facts Agency law Agency prosecutor Agency hearing officer 850-591-4875 jmbarclay@comcast.net

  8. Option 3 – timely requestformal hearing Petition for formal administrative hearing Disputed issues of material facts Filed with Agency but heard by Administrative Law Judge Significantly levels the Medicaid/Provider playing field 850-591-4875 jmbarclay@comcast.net

  9. Option 4 – programmatic challenge • Filed with and decided by Administrative Law Judge Expedited discovery Hearing in 30 days Increased attention to issues Escalates stakes and puts issue/Provider on radar 850-591-4875 jmbarclay@comcast.net

  10. Option 4 – disposition of rule challenge Final Order issued by Administrative Law Judge Significant restrictions can accompany Final Order Right to judicial review 850-591-4875 jmbarclay@comcast.net

  11. Using outside influence Exercise carefully Swarm of gnats Nuclear strike 850-591-4875 jmbarclay@comcast.net

  12. Steps in formal administrative hearing Assignment of Case Number and ALJ Initial Order Pre-hearing instructions Hearing within 30 but not more than 90 days 850-591-4875 jmbarclay@comcast.net

  13. Discovery and motion practice Depositions Requests for admission Requests to produce Motion practice to enforce compliance with procedural rules 850-591-4875 jmbarclay@comcast.net

  14. Receipt of testimony and evidence Live and video capability Opening statements Testimony under oath Documents in support of positions Closing statements Electronically transcribed 850-591-4875 jmbarclay@comcast.net

  15. Post-hearing and Recommended Order Trial transcript Submit proposed recommended orders annotated to trial transcript ALJ submits recommended order to Agency 850-591-4875 jmbarclay@comcast.net

  16. Exceptions to Recommended Order Deadline Filed with Agency Agency usually bound by findings of fact Agency has latitude with conclusions of law 850-591-4875 jmbarclay@comcast.net

  17. Final Order Issued by Agency Head Written disposition of issues Addressesexceptions to recommended order May adopt or articulate findings of fact and conclusions of law Filed with Agency Clerk Notice of appellate rights 850-591-4875 jmbarclay@comcast.net

  18. Judicial review District Court of Appeal Agency headquarters Provider’s location 30 days from rendition of Final Order to appeal 850-591-4875 jmbarclay@comcast.net

  19. Session take-aways Involve competent counsel at the outset Determine deadlines Confirm receipt of Agency Notice Select course of action and take timely action Formal administrative hearing keeps options open and levels playing field Companion rule challenge/challenge to agency statement can increase stakes 850-591-4875 jmbarclay@comcast.net

  20. Thank you for your attention 850-591-4875 jmbarclay@comcast.net

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