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//////////////////////////////////////////////////////+8//////////////////// //////////////////////////////////////////////////////////////////////////// //////////////////////////////////////////////////////////////////////////// /////////////////////////wMAAAAAAA== ------=_NextPart_01C66B78.DE00F4D0 Content-Location: file:///C:/515444C5/preconference_files/pres.xml Content-Transfer-Encoding: quoted-printable Content-Type: text/xml; charset="utf-8" ------=_NextPart_01C66B78.DE00F4D0 Content-Location: file:///C:/515444C5/preconference_files/slide0001.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Preparation for a Medicaid Durable Medical Equipment Hearing April = 5, 2006 Capitol Place Hotel, Austin, Texas Sponsored by the National AT Advo= cacy Project, Buffalo, NY Project of Neighborhood Legal Services, Inc. Advocacy, Inc., Austin, TX
Preparation for a Medicaid Durable Medical Equipment = Hearing

April 5, 2006

Capitol Place Hotel, Austin, Texas

Sponsor= ed by the National AT Advocacy Project, Buffalo, NY
= Project of Neighborhood Legal Services, Inc.
= Advocacy, Inc., Austin, TX
Presenters:
  Steven Elliot, Esq. Jennifer Giesen, Esq. =
    Advoca= cy, Inc., Austin, TX Minnesota Disability Law Cen= ter =
= Diana Straube, Esq. & James R. Sheldon, Jr., Esq.
= National AT Advocacy Project, Buffalo, NY
------=_NextPart_01C66B78.DE00F4D0 Content-Location: file:///C:/515444C5/preconference_files/slide0001_image001.png Content-Transfer-Encoding: base64 Content-Type: image/png iVBORw0KGgoAAAANSUhEUgAAAOEAAADCCAAAAACa4Po+AAAABGdBTUEAALGOfPtRkwAAAAlwSFlz AAAO1AAADtcB9xJNEgAAB3FJREFUeF7tnevW4yoIhr/u+7/nbuMh0VQQEJR02jU/Zlat4eFFJOQw r/ffl3/++3K+v78f4fMl/n4NX+xM8/r7g3/zQr7bFA7fryGbMEgIfl7hS+z7LSpyCccA4xFrQbmE a63TOBoz01AEYucuDQ54Dp6GDlPl0D0cwpBInOkzxAsDGIToRkg51p4xdMKHAnI0fGKIcqL0kWvw WBfE3eLiu/aLK+u0e4izbEQirJdgpqkx8hyF0xkhPdPA1Wj+5p3RKFXBwrRKIXy9i/HFsPrf3hfo kPD1wgM54C8URHCoEWFQqENwBuIAX2CQ+k9wwnGd5lxAwn6IE/STiq9Ug2sIrbF3hOiHqDdVR+sQ 61moLxmTCYWEQcR+DjIxcmpSIeFR7nkLR8APYkLYr29f/TYhIZoufYkrI/S1H+DLVEYY1uD7aP8+ 4SMjHJF5gpcT+lptWv3S9rKEJ6XUCGsoZ7sCxMiJ0uNU8SmxefEyCDsNUyBOXalLJ/zsZWBlzSjb rvueStg9U3pEzBIJWQvQVy1A6ZeeC5C8PYSF6CYlETR8yomg9OzpkTtEDTvU8BHZBMvMQ0JhWk+9 Kg8fK0IPbMmGHyGiRTgLjn/CfW7x40e2xhKxhifRSXaj9LIQZYStYFVWcSikjNBpQHbN0iH0EpE9 RB3CrvOcFOBKhB0RvSxJFUIvMIbrMPSH3SYfFQ37dE66NVqEfkXUInQbpHqVd0fEtwthfxoyos/J Dn+3+KchQ8Pe7uBgm7TV0EOxo0noZIu/hZ0mYSeiHewXqoQ+NsC1GjISldVQVQ17T5duz6bKhB9C 7M+m1oRWsUef15xwezY1J6Q722jkj3DesbvD9KfhvIa7+3CseybIu3fYBauJWcdQcGk7hU2U3lxB 9ow63j9xDZgRQUwlmkdMNxZvNlFqEW3SOZcQblRw2b0YzAiX6qV5hTTelhD/XLdkaNqlN5csSju3 lgRQ2Kqd7Q0JIfhUYvPFxsBsXC0hRCJoa07p26VMWIVq+9jQvjMMbUK9DKE1kyHhrQW+a10aEmqJ MDnPJCGaWaZFVJF9kpDh34k0O0VqStiKKHgmMzxpdXymHiw2JZx775LSVXNbwrZHs+f6ojHh7jbU 8i4Gp7KJ6UXh/nFrDSdFLFl0IpuaE972kwlTGTtTPdSekBOZlWXx9VPQC9M4sPaEwZpLOMapcKIL e2F8ooPDZNERHhRvgh1bL5qXaNg4lWW7wha6iLDC4hZvEwEaPbuEkG/k4ZG0IRb9WdKvzaVp465F pGeNWHVHWr6TylGWaHhHGtbUvTcVSkVcRVhrQNCDMIQaCasIm7eiDDJkLfH8Y41IgEvDIju3qkeO v4bZ3sfB0gHRF2YeQ8O4/Iv4l1jeyoRdp+HNPpL/DnecSUoGaLhb5AbEtVyoBer9DRWFjOSTz9Vp rWHdZqmXH1ygQiDS8saaMPn07CbV5sMopxDCwGyEXEOYMUuhEv8JaCKMRXjvQAg1HNg58LkXSMOO uhHmcQs1PC07YvaK3sbg6kU/H2IKPb6DMK/MtCc2IL0Xo1ceEEXwLsJk91GxVGY3dUBPMgniVsLb 69Ek9o8XJXZaYnNE2KbcmakyUOnVpIovVm9jpNuIrRoC1h4laGZLF2bKR1SGeyJUuNDU8Zknwmye 8otg3BG2C+2klecEEuHKF+w0l0NjM7hpD/BJ6S0e/tzstHf/QXPelN5yR7e3TEb/BZewdj33t2VF luIuVgeJkL1frCG8xOGxZi+d/YzUDOHFBmkd8qZER/NemsXzR//AqwlLPUpMXp+dVaaCi7r6kKoU Qa8zLWEkTa3Dyp+f8cRz9igeQxurNCPpJkef0IfXNoDWV4N4hNEWRKWAF9MoP58qr0M+VkWFrc2R xrBzlAmFa6XFHE5C7bzGidwRxjoN+B+YREJ6JIwVzFS811HglbAfqWXr4ITpswgl1d/jCNNaZMTw 4wjTdX3G7XLPIyylATWxPpIw9RWJiM8kzLegkBh9EjZdUvjMBK5kK3afhMO6LS1G0vU55XOL+kZL ipmfY0iRl34WATv7Rkq2ZWpvGjIAARXvbQFnGnIAk45wWs0q+tKQDRhPRPAbdH0R8pfuOOv6iFKB dmNnrI1S1NXDmzHHNMiIJVGaEAAQM748sXmUtgHY7l4mwVnJGY9mTAgxXBfopyJw9ON4Owv5XHLc L2VKQj05GGEg31MJcSGuAzAJJyyn/tQvIRZYLD8Sr6ku15C8crKWMLQrQi4WGqknM+1/gLPVUJWs g03JpeqE1lAN55Kapj6iwpO91EyaxsEasnIW/aBL9UMJtQGXkxWngxpqEm6jwzTUA9yKB69DJcDd dLCGOoAe+O65VIcsrnEfePcoVQN0g9cSfiVffS+GGiB9918y8twPNQA9BefpPbAuZVurfAO6mr5F w15LjC4r2x1q9o8nyoQVTNdaHNYzYDm3yASIqQija8Dz4fHxHg0i+gZMhNQb4PuQTyAcL1e0qeUb kdKnaR3wKeS3EZ68F6prxIlO1MnlGpBxZYa8WJ0NnNDQGQlkzvcT/g//zMNEJGDsEwAAAABJRU5E rkJggk== ------=_NextPart_01C66B78.DE00F4D0 Content-Location: file:///C:/515444C5/preconference_files/slide0002.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Preparation for a Medicaid Durable Medical Equipment Hearing April = 5, 2006 Capitol Place Hotel, Austin, Texas Sponsored by the National AT Advo= cacy Project, Buffalo, NY Project of Neighborhood Legal Services, Inc. Advocacy, Inc., Austin, TX
How a DME Case Starts
The Due Process Notice and Req= uest for Hearing
<= span style=3D'mso-special-format:nobullet;display:none'>•Timely Decision-Making Required
•= Reasonable promptness requirement.
•
<= span style=3D'font-size:94%'>•= State agency must “furnish Medicaid promptly without any delay caused by the agency’s administrative procedures.” 42 C.F.R. § 435.930.
•
<= span style=3D'font-size:94%'>•= For DME, state Medicaid agencies generally use a prior approval process. =
•
<= span style=3D'font-size:94%'>•= States allowed to set time limits for prior approval, but must be reasonable.
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Notice of Adverse Decision
<= span style=3D'font-size:88%'>•= Medicaid agency must sent out notice to Medicaid recipient whenever the agency takes “action” against the beneficiary.
•
<= span style=3D'font-size:88%'>•= “Action” – includes “termination, suspension, or reduction of Medicaid eligibility = or covered services. 42 C.F.R. § 431.201.
•
<= span style=3D'font-size:88%'>•= “Action” – may also include an “approval” of service if approved with modifications= . Ladd v. Thomas, 962 F.Supp 284 (D. Conn. 1997).
•
<= span style=3D'font-size:88%'>•= Denial/approval with modification of DME request is an action and requires timely and adeq= uate notice.
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Adequacy of the Notice
•The Medicaid Act, Regulations Require: =
•=
<= nobr>•= Statement of the proposed action.
•=
<= nobr>•= Reasons for the proposed action.
•
<= nobr>•= Specific regulations supporting the action.
•
<= span style=3D'font-size:88%'>•= Explanation of the person’s right to request a hearing and the type of hearing availab= le to the individual.
•=
<= span style=3D'font-size:88%'>•= Description of circumstances under which Medicaid eligibility or eligibility for a specific service is continued pending the outcome of the hearing.
•
•<= span style=3D'font-size:75%'>42 C.F.R. § 435.919
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Examples of Defective Notices
•“Not medically necessary.”
•
<= nobr>•“Fails to meet prior authorization criteria.”
•
<= span style=3D'mso-special-format:bullet;position:absolute;left:-4.43%;text-alig= n: left'>•“Does not meet the criteria of Medicaid’s durable medical equipment regulations.”
•
<= span style=3D'mso-special-format:bullet;position:absolute;left:-4.43%;text-alig= n: left'>•Does not state time limit for requesting the hearing (NY cas= elaw on “tolling” statute of limitations).
•
<= nobr>•Does not explain “how” to request the hearing.=
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RESEARCH
&
INVESTIGATION<= /div>
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Research & Investigation Steps
= •Telephone screening
<= nobr>•Client interview
<= span style=3D'font-size:88%'>•= Check written notices, determine deadlines for requesting a hearing <= /span>
<= nobr>•Factual investigation
<= nobr>•= Review the Medicaid agency’s file
<= nobr>•= Medical or disability-related research
= •Legal research
<= span style=3D'font-size:88%'>•= Gather supporting documentation, including expert reports
<= nobr>•= Evaluation of case merit
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Interviewing Clients and Witnesses
= •Establish trust=
= •Be a good listener
= •Take good note= s
= •Build a narrati= ve
<= nobr>•Probe for addit= ional information
<= nobr>•Help the witness remember by:
–setting the scene;
–triggering det= ail; or
<= nobr>–using other so= urces.
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Evaluation of Case Merit
•Research the legal elements= you must prove.
•
•Analyze whether the facts of this case meet = the legal elements.
•
•Determine how you will pro= ve those facts.
•
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Determine wheth= er you can dispute the reasons the AT was denied.
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Medical Justification Letter – Part I
•Introductory sentence =
•
•Professional credentials&#= 13;
•
•How you know this patient&= #13;
•
•Patient’s diagnosis and prognosis
•
•Description of = the current device
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Medical Justification Letter – Part II
<= nobr>•= Explanation of how it is failing to meet patient’s needs.
•
<= span style=3D'font-size:88%'>•= Description of the requested device, including, if necessary, how it meets the DME definition.
•
<= span style=3D'font-size:88%'>•= Explanation of how the requested device will meet the patient’s medical needs.
•=
<= span style=3D'font-size:88%'>•= If the patient did  not need the device b= efore, explanation of why it is needed now.
•=
<= span style=3D'font-size:88%'>•= How this device is the least costly, equally medically effective device.
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Attempt to Resolve Without a Hearing
•Always good strategy
= –Saves time for client
<= nobr>–Saves resources for P&A
•
<= nobr>•Decide whether to request hearing first, then negotiate.
•
<= span style=3D'font-size:88%'>•Even if negotiations do not lead to full resolutio= n, you can:
<= nobr>–Clarify issues in dispute…avoid wasting time at hearing;
<= nobr>–Resolve one or more issues in client’s favor; or&#= 13;
<= span style=3D'font-size:86%'>–Have opportunity for “free discovery”…to review strengths, weaknesses of agency’s case.
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Developing a Theory of Your Case
•Each hearing could involve one or more of the following
•elements to establish the right to DME:
•Individual must be eligible for Medicaid.
•
•Services or DME sought must be “covered”
–For an adult, must be either a required service, o= r an optional service that state has elected to cover.
–For a child, service must be among the federally required or optional services.
•
•Are services covered by another funding source?= 3;
•
•Are services medically necessary?
•
•Are services the least costly alternative that wil= l meet the individual’s needs?
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Hearing Logistics
•Will the hearing take place in person or by phone?
<= nobr>•&= #13;
•What is the scheduled leng= th of the hearing?
<= nobr>•&= #13;
•How will the hearing be recorded?
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Location of Hearing
<= span style=3D'mso-special-format:bullet;position:absolute;left:-4.43%;text-alig= n: left'>•Do hearings take place in the recipient’s home county or at = the Medicaid agency?
•
<= span style=3D'mso-special-format:bullet;position:absolute;left:-4.43%;text-alig= n: left'>•Are the hearings at the county social services offices? =
•
<= span style=3D'mso-special-format:bullet;position:absolute;left:-4.43%;text-alig= n: left'>•Do hearings take place in a conference room large enough to accommodate all of your witnesses?
•
<= nobr>•Can the hearing be held at your client’s home?
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Know Your Hearing Officer
•Are they an employee of the Medicaid agency?
<= nobr>•&= #13;
•What are their qualificati= ons and background?
<= nobr>•&= #13;
•What is their record on si= milar cases?
<= nobr>•&= #13;
<= nobr>•How do they con= duct hearings?
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Hearing Procedures
•Are pre-hearing disclosures required?
<= nobr>•&= #13;
•How are subpoenas obtained= ?
<= nobr>•&= #13;
•Is the proceeding like a fo= rmal court hearing?
<= nobr>•&= #13;
<= nobr>•Do the rules of evidence apply?
<= nobr>•&= #13;
•Who has the burden of proof?
<= nobr>•&= #13;
<= nobr>•What is the role= of the Medicaid agency?
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Introducing Evidence
•Organized, labeled and paginate exhibit books are strongly recommended
•
•Documents should be used with witnesses even= if formal introduction is not required
•
•Should the AT be introduced through video ta= pe or demonstration
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Construction of Direct Examination
•Construct your direct exam with your case th= eory in mind.
<= nobr>•&= #13;
•Be sure to cover the facts you need to prove your case.
<= nobr>•&= #13;
•Anticipate the cross exam.<= /nobr>
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Organize the Direct Exam in a = Persuasive and Logical Way
•Start by accrediting the witness.
<= nobr>•&= #13;
•Organize your questions by topic or in chronological order.
<= nobr>•&= #13;
•Utilize the doctrines of primacy and recency= by starting and ending big.
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Conduct a Persuasive and = Interesting Direct Exam
•The witness is the star of direct exam.
<= nobr>•&= #13;
•Use simple non-leading questions.
<= nobr>•&= #13;
•Use head notes to signal a change in topic.
<= nobr>•&= #13;
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Keep a steady p= ace to your questions and avoid long pauses.
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Preparing a Witness for Direct Exam
•Explain to them how the hearing is run and t= he roles of the players involved.
<= nobr>•&= #13;
•Tell them about the questions you plan to ask and the order of your questions.
<= nobr>•&= #13;
•Prepare the witness for the cross exam questions.
<= nobr>•&= #13;
<= span class=3DBB style=3D'position:absolute;left:-4.19%'>•Help the witness understand how much information to give in response to a question.<= /div>
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THE
EXPERT WITNESS=
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Direct Examination of the Expert Witness Organizational Structure
<= nobr>•= Introduction (identification and relation to the case)
•
<= nobr>•Qualifications
•
<= nobr>•= Tender the witness as an expert (if necessary)
•
= •= Role and overview of basis for opinion
•
= •Opinion
•
<= nobr>•E= xplanation of opinion (educating the decision maker)
•
•= Conclusion – end strong!
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Statement of Expert Opinion
(some options)<= /div>
<= span style=3D'mso-special-format:bullet;position:absolute;left:-4.43%;text-alig= n: left'>•State the opinion without giving the basis for the opinion.&= #13;
•
<= span style=3D'mso-special-format:bullet;position:absolute;left:-4.43%;text-alig= n: left'>•Give the opinion and express the (general) basis for the opinion.
•
<= span style=3D'mso-special-format:bullet;position:absolute;left:-4.43%;text-alig= n: left'>•Have expert express basis for and then give opinion.
•
<= span style=3D'mso-special-format:bullet;position:absolute;left:-4.43%;text-alig= n: left'>•Give the expert a hypothetical question as the basis for the opinion.
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Differentiating the Competing = Expert’s Opinions
•How are the opinions similar?
<= nobr>•&= #13;
•How the opinions are different?
<= nobr>•&= #13;
•What is the rationale for = the divergence?
<= nobr>•&= #13;
•Why is your expert correct= ?
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Cross Examination
•Pre-hearing Preparation <= /div>
= •Identify the witness.
•
<= span style=3D'font-size:88%'>•= Get copies of any reports by the witness regarding this case.
•
<= span style=3D'font-size:88%'>•= Compare the report to the letters of medical justification.
•
<= span style=3D'font-size:88%'>•= Review any professional articles the witness may have written. =
•
<= nobr>•= Decide whether, or how, you can use the witness.
•
•= You may decide not to cross examine at all.
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Conduct of Hearing
<= nobr>•Listen to witness’s testimony.
•
<= nobr>•Maintain control of the testimony.
•
= •Be brief.
•
<= span style=3D'mso-special-format:bullet;position:absolute;left:-4.43%;text-alig= n: left'>•Do not ask a question for which you do not know the answer.&= #13;
•
<= nobr>•Do not argue with the witness.
•
<= nobr>•Know when to stop asking questions.
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Prepare and Deliver a Closing Argument
•When to Do Closing?
•Nearly always, but could be extremely short in some case.
•Preparatio= n
•Prior to hearing, prepare general outline of what closing will say.
•Edit outline based on what happens at hearing. = ;
•Short hearings (half day or less)…work off outline= , with very short notes added.
•Longer hearings…plan to edit outline as breaks allow.
<= span style=3D'font-size:88%'>•If submitting a written argument…closing can be ve= ry short.