Mouthful of Medicaid Reimbursement Grievances

The government lies.

And now I have testimony proof. I know I have discussed my North Carolina administrative grievance regarding the dentists, oral surgeons, and orthodontists who hired me to litigate for higher Medicaid reimbursement rates.

Twelve facilities hired me to increase Medicaid reimbursement rates in North Carolina. We are suing for three distinct damages.

1. Higher reimbursement rates going forward, which will positively affect all dentists, orthodontists, and oral surgeons, which is why our case semi-mocks a class action.

2. Retroactive higher reimbursement rates. How far back do you go? How far back does U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) go?  Recovery Audit Contractors (RACs) go back six to eight years. I believe that I just made a novel equitable argument; and

3. Damages for defending against post-payment audits alleging Medicaid overpayments, which costs providers money to defend themselves, which are, to some, harassment, which are rarely accurate.

I defended a 2024 lawsuit for an oral surgeon against a RAC audit, two oral surgeons testified under oath that more than 200 oral surgeons reside in North Carolina; however, only nine accept Medicaid. However, juxtapose the North Carolina Medicaid Director’s testimony that the inverse was true. He actually testified that over 100 oral surgeons accept Medicaid in North Carolina. Who is correct? The biasness of the state government is disconcerting.

How could I prove that we were right? That only nine oral surgeons accept Medicaid in North Carolina? I remembered a case that I had during COVID. An oral surgeon in North Carolina’s Medicaid reimbursements were suspended without notice per 42 CFR 455.23, an allegation of credible allegations of fraud.

We immediately filed a Motion to Stay, Temporary Restraining Order, and Preliminary Injunction, and a Brief in Support filed on Dec. 22, 2020. The parties’ oral arguments on the motion for a Temporary Restraining Order were heard remotely on Friday, Dec.  31, 2020.

The Administrative Law Judge (ALJ) who presided stated in his decision, “The evidence shows without contradiction that the Petitioner is one of only nine oral and maxillofacial surgeons in the State holding both a dental degree and medical board certification in surgery, and that his anesthesiology training enables him to “provide more comprehensive services to his patients, including deep sedation and general anesthesia.” Among his specialties are treatments for “facial trauma, lesion removal and biopsy, and corrective jaw surgery.”

The ALJ also found because petitioner’s practice is known not to limit the number of Medicaid patients seen, that patient cohort receives approximately 75 to 80 percent of the 2,300 to 2,600 surgical procedures performed there annually. The petitioner’s son, who holds credentials similar to his father’s, joined the practice in early 2019. The two physicians have a staff of nine employees. At the TRO hearing, respondent readily conceded that the suspension of all the petitioner’s Medicaid payments would cause his practice irreparable harm due to its preponderance of Medicaid patients but argued that he failed to show evidence forecasting the likelihood of success on the merits.

The decision held that “It is appearing that that there has been no proof of likelihood of harm to the agency, and that the Department is likely to be in a position to recoup the modest amount in controversy should this Temporary Restraining Order the dissolved, no bond is required.” Not requiring a bond is significant, as bonds are usually required.

That 2020 case stemmed from a RAC Audit. Public Consulting Group (PCG) had accused him of an alleged overpayment of slightly more than $6000. Then PCG referred him to Medicaid Fraud Division. The state then determined that PCG’s referral was a credible allegation of fraud.  As many audits that I have debunked over the years conducted by PCG, a referral from PCG would not be a credible allegation of fraud. Attorneys such as David Glaser and I dispute audit findings every day.