I have now battled 2 states on many Medicaid issues and won every one based on clear, plain language statute. There should have been no argument. It was made difficult as Information was hidden from me, misinformation given to me, and inquiries not responded to. I can not get passed the gatekeepers where an attorney could. Every attorney, every firm tells me that they only deal with finance planning and eligibility, and the system is too broken and to large for their resources. I am just a retired electrician and I am winning landmark cases, but my wife requires my 24/7 care and attention. It astounds me, as I win each case, that our much criticized Congress has really legislated great programs for us for many years, but they are prevented by the state administrators. What Congress has intended is not reflected in state programs and the beneficiary is cheated, the service providers are cheated, the logistics for continuance of the programs are cheated, and Congress is cheated because they are blamed for the supposedly inadequate Medicaid program. Here is a recent example. Congress has legislated caregiver respite hours for family caregivers. 600 hours per year in this state.This Managed Care Contractor got the idea that respite can not be provided on the same day as attendant care, no matter what times or how many hours. The MCC has had this self made policy for over 15 years. That is a lot of caregivers, paid care workers, agencies, the program, cheated while the MCC kept the money designated bu Congress for the service. The MCC was not only allowed, but encouraged by the State Medicaid Authority to do so in spite of plain state policy.
AMPM 1250-7 page 89
If respite care is provided in the member’s own home, all HCB services included in the member’s service plan may be provided in conjunction with respite care. Examples are as follows:
1. If the member is receiving personal care services, he/she may continue to receive this service in conjunction with the respite care.
I had battled another state where they had installed a new 15 million dollar system and over the years of programming, the IT people didn't thing that that the special considerations for elderly/disabled were priority. In court they testified that they considered that EPD codes were low priority because they had been little used. The judge was astute and said that it is obvious that they were little used because the system didn't contain them, thus the caseworkers didn't know of them. The state admin had not properly monitored for over 12 years and many people were cheated. That secretary stepped down after that. As I visit caregiver sites I see many of the complaints that I have won. The states have many choices and latitude in the administering of Medicaid benefits and each state is different, but there are some things that are federally mandatory. I just read a comment where someone needed attendant care and the state contractor was not providing it. I downloaded that states regulations and the contractor is wrong in the denial, but the state admin is clueless. Here is what has happened in my state for over 15 years. Again, that is many people cheated while the contractor kept Medicaid funds. This is from a well know long running case begun in 2001 and nothing has changed, as no one has effectively challenged. The state admin gets paid by our taxes to monitor. Ball vs Rogers page 29 line 5
""""Once an ALTCS contract has been signed, AHCCCS leaves most of the responsibility for determining whether beneficiaries actually receive prescribed services up to the program contractors themselves. Dep. of Shafer, 118:14-22.
During the two years in which this lawsuit has been pending, no program contractor has been given a poor performance rating or otherwise penalized for failing to fill beneficiary care plans. Id., 140-141.""""
Ball vs Rogers page10 line 9
""""ALTCS program contractors are allowed to keep the profit that they make by not spending all of their capitation payments on services. Statement of Facts, ¶¶ 116, 119.""""
Ball vs Rogers page 14 line 8
ALTCS Fails To Effectively Monitor Its Program Contractors
The AHCCCS managed care system creates an incentive to
underserve beneficiaries. ALTCS program contractors make more profit if they provide fewer services to the members. Deposition of Mark Hoy 45:1-3, 22-23.
So. Congress intends much more than we are receiving.The statutes are plain even to this retired electrician. Why are attorneys unwilling to battle for the people?
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Say a big multiple site NH group "buys" all it's drugs for its residents from a pharmacy that is owned by some of the owners of the NH or their families and the drugs sold are way way above comparable prices. Medicare pays for the drugs but it could be a stark law violation as its above FMV for pricing. A lot of Stark is about unneeded or substandard quality "equipment" buys on a large scale paid by Medicare...like wheelchairs, beds, walkers with " consultant fees" paid to MDs or facilities to order/buy from a specific vendor which the MD or owners of a facility may have ownership in or get a commision /consultant fee from as well.
Ellery - if any of the above is your situation, you can file a stark law concern to CMS for things or services Medicare paid for . You'll likely get a TY letter back from CMS but after that whatever happens seems to totally become an internal federal investigation - they have all the past billing & payment info & history so don't need to involve you.
Perhaps the biggest problem though is locating class action plaintiffs. Handling a pharmaceutical class action suit might be easier because there's more available information on drug side effects and damages. People suffering at the hands of dishonest Medicaid contractors are likely going to be harder to locate.
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Yes I have approached the matter as fraud to state attorney general last year, no response. With all the silence and misdirection I receive, I have to wonder who is in who's pocket.
It is fraud because the MCC gets to keep the capitation by not providing services. Someone has been profiting for many years by exploiting Medicaid.
Since these things have affected so many I am trying to engage some of the dedicated large nonprofits to file a class action on the behalf of everyone else.
I don't need anything for us. We have enough to live daily.
qui tam legislation. I am surprised my searches didn't reveal this. Already I see possibility.
If so, there's an action known as qui tam ligitation, in which an individual, generally represented by a law firm, can sue and recover damages against the entity engaging in fraud. I haven't checked the statute recently, but have a vague recollection that back in the early 2000s the recovery was 3x damages, i.e., 3x the amount of the fraud was awarded to the firm and the instigating "whistle blower."
Google "qui tam legisltation", do some research, and review the cases you've won to see if any would have falled within the purview of the False Claims Act.
I have the impression from your post that you're dealing more with inaction, benign neglect, or something less intentional that fraud, but it's worth it to explore this possibility.
What about the attorneys in the cases you've already won?
The ones who would be in a position to litigate are those in large, well-heeled firms with resources to fund long pro bono actions. And generally they're more corporate oriented.