Georgia Pediatric Program Denial Management

Posted 9 months ago. Applies to United States, 0 helpful votes

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The Georgia Pediatric Program (GAPP) provides skilled nursing nursing services for medically fragile children. Unfortunately, these services are frequently stripped from children forcing caregivers to commit their children to institutional care. These tips may help to keep children's benefits.

1

Know your rights.

Securing skilled nursing services through GAPP is a time consuming effort requiring the caregivers, who are generally the parents, to sign a litany of documents. The 'Letter of Understanding' states that GAPP is intended to serve as a teaching program for caregivers. If the child's condition stabilizes then the hours are generally reduced. If the GMCF medical review team decides to reduce the child's skilled nursing hours, then they provide an 'Initial Letter of Notification' that gives you 10 days to request administrative review. If the caregivers do not exercise their right for review then the reduction in hours becomes permanent. Next, the GMCF generally issues a second denial which gives the caregivers 30 days in which to appeal their case for a hearing before an administrative law judge (ALJ).

2

How do you litigate a GAPP case?

GAPP litigation is unique. Georgia law states that when state agencies receive requests for hearings in contested cases not arbitrated by the agency itself, then the Office of State Administrative Hearings (OSAH) presides. O.C.G.A. 50-13-41(a)(1). The ALJ generally has all of the powers of a state or superior court judge. O.C.G.A. 50-13-41(a)(2); 50-13-13(a)(6). The rules of evidence are enforced in the same manner as state and superior courts. O.C.G.A. 50-13-15(1). Whether the Rules of the Georgia Civil Practice Act apply are a matter of discretion for the judge. O.C.G.A. 50-13-13(b).

3

What children must receive GAPP skilled nursing services?

In order to win your case you need to demonstrate to the ALJ that your child is mandated to receive skilled nursing services under the Medicaid Act. Georgia is required to provide private duty nursing services to Medicaid-eligible children when the services are medically necessary to correct or ameliorate an illness or condition. Georgia may enforce a definition of medical necessity that places limits on physician's discretion but may not limit Medicaid services on the basis of the underlying medical condition. This means that child's treating physician's recommendation may be disregarded by the Department of Community Health (DCH) if they determine that the child's condition is stable. Thus, you have to demonstrate to the ALJ that the child's medical condition will be exacerbated if the child's skilled nursing services are reduced or eliminated.

4

Work with the child's treating physician.

While the treating physician's opinion may be disregarded by the DCH, it is highly persuasive for the ALJ. Ask the treating physician to provide a letter detailing his or her analysis as to the severity of the child's conditions. The opinion of the treating physician is generally given more weight than the opinions of DCH doctors since the doctors for the DCH rarely interact with the child. Instead, they review the case files remotely and render their decisions based on an administrative review of the record.

5

Hire an attorney.

This sounds obvious, but a lot of people attempt to argue these cases pro se. It is a big risk to challenge the DCH without an attorney familiar with Medicaid law. This is a very specialized area of practice and few attorneys litigate in this arena. The DCH will be represented by counsel and their lawyers will argue the legal merits of their case.

Additional Resources

The opinion of Moore vs. Reese provides an educational foundation for this area of Medicaid law. http://www.ca11.uscourts.gov/opinions/ops/201010148.pdf

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