Recurring Scam Withdrawals Result in Medicaid Application Denial

A New Jersey appeals court has ruled that the Medicaid agency properly denied an application on the basis of the applicant failing to "verify" recurring transactions on the applicant’s bank statement even though the transactions may have been part of a scam.  G.M. v. Division of Medical Assistance and Health Services (N.J. Super. Ct., App. Div., No. A-0433-19, June 16, 2021).

G.M. suffered from dementia and lived in a nursing home. In 2018, she applied for Medicaid benefits and submitted the required bank statements. The Medicaid agency requested verification of recurring transactions from 2013 in the amount of $300 that were labelled:

"ACH DEPOSIT UNITEDCAPITALCRE UNITED CAP" (UCC)." 

G.M.’s authorized representative stated that her family believed the transactions were part of a scam of which G.M. was a victim.  The representative provided supporting "screenshots" to show that the company UCC was no longer in business.  As a result of the foregoing, the representative declared that she could not provide formal documentation.

The Medicaid agency denied G.M.’s application for failing to provide sufficient verifications. G.M. appealed, but the administrative law judge affirmed the denial, stating that there was a lack of evidence that G.M.’s agent under her power of attorney attempted to determine the nature of the transactions. The Medicaid agency affirmed the denial, and G.M. appealed to court.

The New Jersey Superior Court, Appellate Division, affirmed, holding that the Medicaid agency properly denied G.M.’s Medicaid application for failure to provide verifications. According to the court, the screenshots of UCC’s former website did not provide evidence of the purpose of the transactions, so G.M.’s “proof of eligibility was inconclusive."  The "decision to deny [G.M.’s] application was not arbitrary, capricious, or unreasonable.”

The decision does not address what, in addition to the representative's declaration, would suffice. 

HHS Can't Delay Medicare Appeals Backlog Case While Backlog Worsens

The Department of Health and Human Services (HHS) won't be able to push off litigation over its overwhelming backlog of Medicare appeals, a federal court ruled on Monday.  The HHS had asked the Court to stay the litigation, which was filed by the American Hospital Association and three other hospital organizations, until Sept. 30, 2017. HHS asked for the delay to allow the agency to move ahead on administrative and legislative efforts designed to tackle the backlog of more than 700,000 appeals, including implementation of a set of strategies proposed as recently as June.

The U.S. District Court for the District of Columbia's denied HHS' motion to stay the litigation, after describing the agency's proposed fixes as “impressive-sounding action items” that won't do much to curb the backlog as it grows to more than 1 million appeals in fiscal year 2020."  Judge James E. Boasberg wrote:  

“The best medicine can sometimes be hard to swallow,” wrote  “... the backlog and delays have only worsened since [HHS] first sought the Court's help, and the Secretary's proposed solutions are unlikely to turn the tide.”  

In denying the HHS' request, the court nonetheless turned down the hospital groups' request that the Court order the agency to resolve the appeals.     The Court explained that:

“[t]he Court, however, does not possess a magic wand that, when waved, will eliminate the Backlog.  Plaintiffs' suggestion that the Court simply order HHS to resolve each of the pending appeals by the statutorily prescribed  deadlines is extremely wishful thinking."

Of course, among the proposed strategies, one will not find a reversal of HHS opposition to lawful home health care and hospice care.  In other words, HHS appears satisfied with strategies designed to reduce the backlog of cases, but unwilling to reverse the positions that cause the backlog of cases in the first place.  For more information regarding the HHS position on home and hospice care, go here.   

Appealing Medicare Refusal to Cover Care

Sometimes Medicare will decide that a particular treatment or service is not covered and will deny a beneficiary's claim. Many of these decisions are highly subjective and involve determining, for example, what is "medically and reasonably necessary" or what constitutes "custodial care." If a beneficiary disagrees with a decision, there are reconsideration and appeals procedures within the Medicare program.

While the federal government makes the rules about Medicare, the day-to-day administration and operation of the Medicare program are handled by private insurance companies that have contracted with the government. In the case of Medicare Part A, these insurers are called "intermediaries," and in the case of Medicare Part B they are referred to as "carriers." In addition, the government contracts with committees of physicians -- quality improvement organizations (QIOs) -- to decide the appropriateness of care received by most Medicare beneficiaries who are inpatients in hospitals.

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