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Things I will not be doing with my law degree #1

Posted by T. Greg Doucette on Jul 13, 2010 in The 2L Life

Mediating hearings involving Medicaid and the NC Office of Administrative Hearings :beatup:

Yes, I do realize it’s probably not the best idea in the world to swear off potential employment options during one of the worst legal economies ever.

But… ugh.

Earlier today I headed down to Raleigh to join the good folks over at Carolina Dispute Settlement Services, to help mediate a pair of cases as part of my volunteer work with the ADR clinic at the North Carolina Central University School of Law. The cases for today were both from the NCOAH, which basically deals with just about any kind of dispute or claim involving the state government — including reductions in allowed Medicaid services.

Essentially the state has hired a contractor to evaluate Medicaid services on a person-by-person basis each quarter, and to determine during that quarter the number of “units” (15-minute increments of service) a given patient is allowed to receive. The patient and his/her physician(s) are notified and given the chance to appeal if they don’t like the number of units authorized. In appealing a determination, the patient or his/her physican(s) (dubbed the “Qualified Professional” or Q.P. in the hearing) have to prove the services reach the threshold of “medical necessity”; fail to do so and the appeal gets dismissed.

The first case was so flagrantly absurd that alarm bells kept going off in my mind that this had to be Medicaid fraud. The patient was only going to therapy once a month. The “Qualified Professional” who was representing her in the hearing didn’t know some of the most basic medical terminology1 and clearly had no clue about her treatment history.2 The argument against the reduction in allowable service hours kept focusing on “the team” — the group of physicians administering treatment — and whether “the team” would have enough money to operate without the added units… not on whether the patient needed or would benefit from the treatment.

And during the questioning back and forth it came out that some of the “treatment” involved things like a physician’s assistant going to the patient’s home and driving her to the grocery store and back. In other words, not actual treatment :crack:

The lady representing the State of North Carolina (justifiably) refused to budge, and the hearing was over 15 minutes after it started with the appeal essentially withdrawn… and me wondering why we even have Medicaid if it can’t be properly administered.

Then we have another hearing a few hours later, and my mental pendulum ends up swinging to the opposite extreme…

The patient was an adult male with mild retardation, who was sexually molested by his mother regularly up until he got married, and hasn’t been able to successfully keep any kind of regular employment since because he talks to anyone who will listen (including co-workers) about his sexual trauma. He has since married a woman 20 years his senior, who has 4 kids of her own (3 of whom are also mildly retarded), and they’ve moved in with one of the daughters-in-law in what is charitably described as a non-conducive environment for developing normal familial relationships. Meanwhile the mother keeps pleading with the patient to divorce the wife so the mother can have him back, the patient is depressed and insists on having sex with his wife at least 3x a day to keep him happy, one of the daughters is also depressed and has gained so much weight from eating that she’s on the verge of death, etc etc etc.

The story goes on, but you get the picture.

The rep for the State tried to make the argument that physicians can’t rehabilitate someone who was never habilitated, basically saying it wasn’t Medicaid’s job to help this particular individual and he needed to look elsewhere for treatment. Fortunately the patient’s representatives in this case were the polar opposite of the QP in the earlier hearing, with two physicians, the treating psychiatrist, and a manager of the medical firm all at the hearing and responding with boatloads of data and medical information pretty thoroughly detailing the medical necessity of continued treatment.

Even though I was there as a “neutral” third party, while the parties were talking back and forth I could feel myself getting angry that the government was even considering cutting treatment for this guy, when they allowed any treatment at all (even if it was a reduced quantity) for the first case :mad:

The hearing for that one took over an hour, but eventually the representative for the State acquiesced and agreed that the patient would get the extra units of treatment per week requested in the appeal… at least for the next 90 days, when the case comes back up for another review :beatup:

It was an interesting learning experience, but I don’t see me being able to do this type of stuff professionally. I’m already not a fan of doctors or government so I end up hating both sides. And honestly sitting through a long detailed analysis of the travesties facing some folks receiving indigent care (like the 2nd hearing) really crushes the spirit.

I’m not trying to be Pollyanna-ish and pretending like those travesties don’t exist, I’m just saying I’ll let someone with the emotional stamina to deal with it every day handle these cases while I devote my time to locking up people who do things like molest their developmentally-challenged children into their 20s…

Hopefully the rest of you had a more cheerful day than I did :) Have a great night y’all! :D

  1. For example, the different between a delusion, a hallucination, and an intrusive memory. I’m not medical expert, but I know enough to know these are 3 different things. The “QP” did not :crack: []
  2. Pausing the hearing multiple times to turn to the patient and ask information about her treatment, but not letting the patient speak herself. []

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