Legal Counsel for Medicaid and MO HealthNet Investigations, Litigation and Consulting

In Missouri, the Medicaid assistance program for disadvantaged communities and persons is known as MO HealthNet. Medicaid service providers may be investigated or terminated from the MO HealthNet program by the Missouri Department of Health and Senior Services (DHSS). See also Medicaid & Medicare Contracts. Termination from the program can end your ability to provide services or receive payments, causing you to lose your job or your company. If you receive notice from the state that your participation in Medicaid or MO HealthNet is being investigated or terminated, you must act quickly. Contact the attorneys at Dolley Law, LLC for immediate, effective representation to protect your employment and your business.

The MO HealthNet Program

Missouri citizens who are eligible for MO HealthNet programs receive medical care and services that are covered by government payments. These services include inpatient hospital services, outpatient hospital services, nursing home services, physician’s services, personal care services, and more. Personal care services include in-home medical care.

Individuals or businesses who provide these services, such as hospitals, nursing homes, and home health agencies must follow federal and state requirements in order to participate in and be reimbursed by MO HealthNet. Complaints made to DHSS, routine audits, or internal investigations may lead DHSS to allege that a participant has violated program terms or a provider agreement. If DHSS believes these allegations are substantiated, it may send notice that a participant is being terminated or suspended from the program. DHSS may also deny or seek reimbursement of amounts previously paid or billed. If you or your company receive a notice from DHSS, you must act quickly to ensure certain deadlines are met and your rights are protected.

Conduct That Could Lead to Program Termination

Under Chapter 208 RSMo and state regulations, an individual, corporation, clinic, association, or partnership may be terminated from MO HealthNet for the following reasons:

• Providing a false claim for services;
• Submitting false information for purposes of obtaining greater compensation than allowed;
• Failure to make records available;
• Breaching the terms of a provider agreement;
• Civil or criminal fraud;
• Violating laws, regulations, or a code of ethics;
• Failure to maintain contemporaneous documentation;
• Failure to submit and document actual time spent providing a service;
• Failure to make reasonable effort to review claims for payment.

The Investigative and Legal Process

The Missouri Medicaid Audit and Compliance Unit (MMAC) may begin an investigation in response to a complaint from a recipient or on its own. The assigned investigator may seek records from a MO HealthNet provider and may ask to interview the provider, its employees, and witnesses.

If MMAC determines the alleged conduct occurred, it issues notice of its intent to terminate participation in the program. An individual or entity that receives such notice has 30 days to appeal the determination to the Administrative Hearing Commission (AHC). The AHC is a judicial body in Jefferson City that hears and adjudicates administrative cases. Those filing an appeal may seek a stay of the determination to allow their business to operate while the case is pending. It is critical to seek representation immediately, as corporations cannot represent themselves and legal and procedural requirements must be met. Failure to obtain a stay order may cause your business to be unable to bill for services during the appeal, which can be a lengthy process.

Individuals or companies that file appeals have the right to hearing before the AHC. They can seek records from MMAC, subpoena witnesses, testify, present evidence, and cross examine witnesses. A successful hearing results in a finding in your favor and continued participation in the MO HealthNet program. An unsuccessful defense means being barred from the program, potentially for years, and possible repayment of billed amounts. An individual who is terminated from the program cannot work for an entity that receives state or federal reimbursement. Those terminated from the program cannot submit more claims or receive payment for services provided to Medicaid participants. Companies and individuals who work in this area need competent, aggressive representation to protect their rights, careers, and businesses.

Consultations to Ensure Compliance

Dolley Law, LLC is available to advise and consult individuals and business who provide services under the MO HealthNet program. See Preventative Counseling. Our attorneys can advise you on best practices and review your internal policies to ensure compliance with your provider agreement and relevant state and federal laws. Making sure your business is in compliance can save you from a costly and potentially devastating investigation and payment suspension in the future. Dolley Law, LLC can act proactively to ensure your business can continue to operate and receive payment.

Contact Us

If you are notified that MMAC or DHSS intends to terminate you or your company from Medicaid or MO Health Net, or you desire a consultation to ensure you are in compliance, contact Dolley Law, LLC by calling (314) 645-4100 or by email at kevin@dolleylaw.com.