Complex rehab: Holding MCOs legally accountable

Friday, April 5, 2019

BUFFALO, N.Y. – NCART and Neighborhood Legal Services, a nonprofit that provides free legal services to people with low income and people with disabilities, are teaming up on a new effort to call out managed care organizations for their failures to follow Medicaid policies.

Here’s what Marge Gustas and Joe Clark, a paralegal and attorney, respectively, who will be speaking at the National CRT Leadership & Advocacy Conference on May 1, had to say about legal strategies to hold MCOs accountable.

HME News: How are MCOs running afoul of Medicaid policies?

Marge Gustas: A common problem is when the managed care plans use their own policies to evaluate a Medicaid recipient for complex rehab. Is that appropriate for them to do? Yes, but if and only if those policies are no narrower than Medicaid.

Joe Clark: They can offer more, but they can’t offer less.

HME: So NCART and NLS are trying to better coordinate responses to these failures by MCOs?

Clark: What we want to do is to call managed care plans out for their failures to follow Medicaid policies through a mobilized national network of legal advocates who can go through the legal process and push those rights forward.

HME: What’s your strategy for confronting MCOs?

Clark: We’re in the very beginning stages of contacting the managed care plans on this, but it’s going to be a multi-pronged strategy. You want to be friendly at first and try to convince them that they’re wrong, because the legal route is expensive and time consuming, and that whole time a person is without the equipment they need. If they don’t change on their own, then there’s the legal component. That hits them in a number of ways—in the wallet, with bad publicity. And there will be a cumulative affect, as we do this across the country.

Gustas: We want the plans to understand that there are people who are aware of how their process is going and it’s not always the appropriate way.