I recently underwent partial dental extractions. The second part of the procedure was scheduled however the clinic cancelled due to changes with Illinois Medicaid billing. What recourse do I have?
Country relating to Question: United States
State (if USA): Illinois
Have you filed your written appeal to medicaid yet?
No I haven't filed an appeal. I was scheduled to have the final extractions done July 5th and was notified on that day that my appointment was cancelled.
I am afraid that the first step here is you would need to file a written appeal with medicaid together with a report from your doctor explaining how the procedure began before their change and that it is medically necessary for it to be completed to seek to have medicaid waive their restriction or denial. If medicaid does not reverse on their first appeal, then you can request a state fair hearing through the medicaid board. Unfortunately, this is the only process when medicaid changes their payment rules. It is helpful to you if they deny your first appeal to get a local medicaid attorney, most who take these cases and are paid by medicaid to represent poor people in need of medicaid and you can find one by using the same site used by other attorneys, http://www.martindale.com or calling the state bar and asking them for the pro bono or medicaid attorneys in your area.
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I understand that I can file an appeal through Illinois Medicaid however, what about the DDS that is refusing to finish/ complete a medical procedure because due to finances. As a provider, they were fully aware, prior to service of upcoming changes in payment by Illinois Medicaid. Had I been informed I would not have began the process without security that the procedure would have been completed. I believe it is unethical for the provider to refuse to complete the extraction process. I feel that I have been abandoned as a patient by my provider.
While the provider, even when they take medicaid, still has a right to be paid for their services, if you can prove they started this procedure knowing that they would never be able to complete it because they were aware the new rules would prevent them from doing so, then you can consider a malpractice claim against the dentist. However, in IL, this means you would need another dentist as an expert to attest that a reasonably trained dentist would not have started such a procedure knowing they would not be able to complete it. Without such an expert, the IL law prevents you from even filing suit as any suit without an expert report attesting to the negligence of the doctor must be dismissed by the court.
Thank you. What qualifies a dentist as a dental "expert"? Would this "experts" position have to be documented in a particular format?
Any dentist who is licensed in the state who performs similar procedures would qualify as an expert. The experts have to write a report which is a notarized affidavit.
Last question Paul. In your professional opinion, which case would be easier to prove? Should I seek to prove negligence on the part of the doctor or should I seek an appeal/ waiver through medicaid?
Honestly, you should pursue both, because in law, you are entitled to pursue multiple avenues or theories for recovery. Certainly though the dentist deserves to be paid, but if he knew he would not be paid in advance he should have told you that before he began the procedure.
JA Mentor -Attorney Labor/employment, corporate, sports law, admiralty/maritime and civil rights law
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