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Society brief highlights barriers to Medicaid participation

The Wisconsin Medical Society filed an amicus “friend of the court” brief in the Wisconsin Court of Appeals on Monday in Papa v. Wisconsin Department of Health Services (DHS). The case examines a state Medicaid rule that creates a potential barrier to participation by physicians and other providers and that ultimately could negatively impact Medicaid beneficiaries’ access to quality care.

The Papa case involves the extent of DHS’s authority to recoup payments from participating providers where there is no allegation that a service was not adequately performed or is not a covered service, but rather based on failure to follow all documentation and other technical requirements contained in administrative rules, the Forward Wisconsin Provider Handbook, technical bulletins and other sources.

In a September 2016 decision, a Waukesha County Court found that the DHS’s position that compliance with all technical requirements by providers is a prerequisite for payment amounts to a “Perfection Rule” that exceeded its authority to recoup payments otherwise properly made. The Court ruled that DHS may only recoup payments where either it is unable to verify from the provider records that a service was actually provided or the amount claimed was inaccurate or inappropriate for that service. DHS appealed that decision to the Wisconsin Court of Appeals.

The amicus brief filed Monday details the barriers faced by physicians and others serving Medicaid patients, such as increased administrative burdens and insufficient reimbursement that is near the bottom nationally. It argues that the “Perfection Rule” adds additional burden and uncertainty that threatens to jeopardize providers’ ability to see Medicaid patients, and ultimately “will impact the quality and accessibility of health care for Medicaid beneficiaries in Wisconsin.”

The Society filed the brief jointly with other organizations whose members provide Medicaid providers subject to the rule, including the Wisconsin Hospital Association, Wisconsin Dental Association, Pharmacy Society of Wisconsin, Wisconsin Health Care Association and LeadingAge Wisconsin.

For more information regarding this case or the Society’s judicial advocacy efforts, contact Society General Counsel John Rather, JD.

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