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socrateaser, Lawyer
Category: Legal
Satisfied Customers: 38878
Experience:  Retired (mostly)
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can a long term care facility which made administrative mistakes

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can a long term care facility which made administrative mistakes make you lose your medicaid eligibility because they refuse to provide medicaid determinination justification for their exhorbitant billing

The facility won't cause you to lose your eligibility. Medicaid, however will only pay what it finds to be the reasonable and necessary costs of long-term care. If the facility insists on charging more than that cost, and it similarly refuses to justify its additional costs, then you have the option to refuse to pay the additional amount and let them attempt to evict you from the premises -- at which point, you would defend that you never agreed to pay the charges beyond which Medicaid will reimburse -- or, you can find a different facility and relocate.

What I'm explaining is admittedly the brute force approach to dealing with an uncooperative vendor. However, in many cases, that's precisely what's necessary. You tell the management that you aren't paying anything more than what is considered reasonable and necessary by Medicaid, and if the vendor doesn't waive the additional charges, then you move to a different facility. Plain and simple.

Note: If I'm not correctly understanding your circumstances correctly, please clarify, and I will try to assist you further.

Thanks in advance.
Customer: replied 4 years ago.

As far as I know Medicaid was making income determination up to 2011 and the bill was paid every month on behalf of the family member resident of the facility. Last year the administration told me that payment is no longer due because private insurance is no longer the primary insurance, medicare is. But in December last year the billing resumed claiming that the non billing was due to a "computer glitch". I requested 3 times already that they provide me with a copy of the new determination for 2012 and 2013, to no avail, they keep on sending me 2011 now I have been threatened over the phone today PM that medicaid eligibility will be lost if the account is not dealt with I have till Monday 5:30. I Left two messages today. At this point what is the best course of action?

I would contact one or more of the following resources, and try to get some assistance from the "payor" rather than the "payee." You want to be in compliance, and your complaint is that the facility is making this impossible. That could put the facility's license in jeopardy.

NJ FamilyCare/Medicaid Call Center: Information and Referral Hotline for clients and providers 1-800-356-1561

Fraud and Abuse Hotline: Doctors, Pharmacies, Clients and Other Providers to report Medicaid, PAAD and GA Fraud and Abuse 1-888-937-2835 or 1-888-692-2140

Health Benefits Identification (HBID) Card: HBID information/assistance for providers, clients, County Welfare Agency staff and Statewide Eligibility Determination Agency staff. 1-877-414-9251

If none of the above can assist, then you can try the Division of Health Facilities Evaluation and Licensing, which is the agency that actually licenses NJ long-term nursing facilities:

By Phone Complaint Hotline: 1-800-792-9770


The 24-hour hotline handles consumer complaints and facility emergencies seven days a week. Patients, health care facility employees and other members of the public may file complaints about hospitals, ambulatory surgery centers, home health agencies, nursing homes, assisted living facilities, comprehensive personal care homes, adult medical day care, pediatric medical day facilities, and many other licensed acute- and long-term care facilities.


Hope this helps.

Customer: replied 4 years ago.

Thank you for reply which is comforting,and that I should not pay blindly for something I am definitely not sure that I owe. In the meantime, should I worry about the family member lost of eligibility and quality of care? He is bed ridden, attached to various life support, paralyzed from the neck down and blind and mute.

I do not believe that there is any legal rationale for the loss of eligibility, due to the facility's errors and omissions. I cannot point to a specific statute or regulation, but my educated guess is that the law is not so malformed as to permit such an outcome.

Your good faith efforts to resolve this issue in a timely manner, will probably work in your favor. Government regulators don't like it when their licensees fail to use reasonable care, because it wastes the government's time having to deal with the complaints.

Hope this helps.
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Customer: replied 4 years ago.

I feel that I have been involved in a web of lies and deception.

I sent to the center a last letter to the center quoting your reply and asking again for the Medicaid determination, instead I received a correspondence from their lawyer with a copy of 2012 determination that they always refused to give me (2013 was not included) the lawyer's letter stated that as have control of the familiy member assets and I refused to turn it over I may be subject to the Ombudsman investigation and or criminal prosecution, I am not sure what exactly is going , but my impression is that the lawyer did not get the full picture of the situation for whatever reasons that guide the Center's action.

The comment from the lawyer feels like extortion. Seems as though the lawyer thinks you are hiding assets which were never disclosed when you applied for Medicaid, and the lawyer is issuing a less-than-veiled threat that unless you disgorge some of those assets, you will be reported to the government for Medicaid fraud.

If that's what's going on, and you aren't hiding anything, then you could call the police/sheriff/district attorney and ask that this lawyer be investigated for making the extortionate demand. If you are hiding assets (and I'm not suggesting you are), then you need to be very careful, because you could find yourself in some hot water with the government. I'm not saying you should pay the bill. I'm just saying that if there is risk of some sort of fraud investigation actually turning up wrongdoing, then that would severely constrain your options.

Hope this helps.
Customer: replied 4 years ago.

thank you for you quick reply. To shed more light to the situation, I am a retiree living on a modest pension,which barely pay for the monthly bills the asset that they talked about is the family member $700 monthly social security income. When the family member, who is my spouse, got ill I was left with close to a million dollars in debt and in a pre-foreclosure status. In liquidating everything in the family's name I managed to avoid futher further proceedings. For your information the law firm specializes in debt recovery for nursing homes, probably by any mean necessary.

I do not know if the above will change the substance of your answer.

Actually, your reply sort of amplifies my previous answer. I don't see that the debt collector has any grounds to reach you for anything other than what you originally agreed to pay -- and you're probably judgment proof, so even if you were sued, and you didn't bother to defend, the debt collector wouldn't be able to recover anything from you.

You could complain to the NJ Attorney Disciplinary Review Board, in addition to contacting law enforcement and requesting an investigation.

Hope this helps.
Customer: replied 4 years ago.

The main issue is that contradictory info I received last year, making me believe that I did not have to pay anymore and based on that information and the absence of billing I used the spouse ss to pay the house bills which still befall me. Now the backtracking is I have to pay retroactively even if I did not get the document in a timely manner . My concern is perhaps I may be accused of fraud or something of the sort and have to pay at once the whole amount of close to $7000 which I do not have.

Complaining is certainly an option but will it stop or even halt the process?

I'm not really following your last comments. Can you please rephrase? Pretend you're addressing another nonlawyer and explain things to me as simply as you can. Thanks.
Customer: replied 4 years ago.

I was just summarizing our whole exchanges for you advice on the way forward. In a nutshell: First I was paying, then I was told I do not need to pay, then I was told I need to pay with retroactive effect for the 6 months I was not billed due to errors and negligence and added to that a 4 months of correspondence to have the justification for payment reinstatement which make it a retroactive payment of 10 months. In the meantime I used the funds as household income to pay bills. Now I am threatened with investigation and possible criminal prosecution by a lawyer who act more like an unscrupulous debt collector. My question is while considering filing complains as you suggested, is there a way out to stop or halt this process besides payment. And if this is the case arrangements will have to be made but with who.

You can send a "cease and desist" letter to the attorney, pursuant to the federal Fair Debt Collection Practices Act (FDCPA: 15 USC 1692c(c)). This will stop the attorney's continuing contact, except for the purposes of actually suing you.

There are lots of free sample letters on the internet (Google: "fdcpa cease and desist letter").

I usually instruct the debt collector in the letter that all further telephone communications will be recorded -- that way, the debt collector (who inevitably tries to communicate via phone so as to avoid proof of continuing contact after a cease and desist letter is sent) knows that if contact continues, that contact will be evidence for a lawsuit against the debt collector (15 USC 1692k) or a Federal Trade Commission complaint.

Lawyers, however, are particularly responsive to the risk of discipline by their regulatory organization -- because a license suspension means your "out of business."

Best wishes.