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Handling Medicaid Denial of Benefits Appeal  

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This basic-to-intermediate level seminar is designed for attorneys who are engaged in Medicaid eligibility planning, Social Security disability practice, estate planning and elder law. It will also benefit accountants whose clients face Medicaid eligibility issues, geriatric care or special needs care providers and consultants, and social workers who are engaged in geriatric or special needs care practice.

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Seminar Summary:

The goal of this course is to provide an understanding of the legal environment in which appeals of Medicaid benefit denials are conducted and to offer a step-by-step guide through the basic elements of prosecuting an appeal. (see full course description)

 

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Training Course Syllabus:


Handling Medicaid Denial of Benefits Appeal

What You Need to Know to Appeal the Denial of Medicaid Benefits Effectively
Many of your clients have loved ones entering nursing homes and have sought Medicaid benefits to pay for nursing home care, or have family members with special needs who have sought Medicaid benefits to provide needed care. Countless applications for Medicaid benefits are denied due to imperfections in the applications submitted or in the review of the applications by state caseworkers. The goal of this course is to provide an understanding of the legal environment in which appeals of Medicaid benefit denials are conducted and to offer a step-by-step guide through the basic elements of prosecuting an appeal. Enhance your practice - register today!

  • Review the federal and state legal authorities which govern the consideration of Medicaid benefits applications.
  • Understand the interplay between statutory provisions and local policies under which the Medicaid program is interpreted and implemented by state caseworkers.
  • Explore the procedural scheme under which Medicaid appeals are prosecuted.
  • Learn how to conduct hearings to appeal involuntary discharges from residential skilled care nursing facilities.
  • Identify ethical challenges inherent in benefits appeal representation, including determination of whose legal interests are being protected and whether an attorney must become a witness (as opposed to an advocate) in an appeal proceeding.
 
  1. “Where is the courthouse? What do you mean there is no courthouse?”
    The Administrative Law Environment in which Applications for Medicaid Benefits are Reviewed and Decided
    9:00 - 9:30, Terry C. Cox and F. Auston Wortman III
    1. Federal Statute Authorizing States to Administer Medicaid Program
    2. State Statute Administering Medicaid Program through Department of Human Services
      1. T.C.A. - Hearings and Appeals Process - UAPA
  2. “I didn’t know there were so many laws involved in such a simple case!”
    The Governing Authorities

    9:30 - 10:15, Terry C. Cox and F. Auston Wortman III
    1. The Federal Medicaid Act
    2. Code of Federal Regulations
    3. State Enabling Act
    4. State UAPA
    5. State Administrative Rules
      1. Medicaid Manual
    6. State Case Law
    7. State Administrative Rulings
  3. “It’s a government form. How complicated can it be?”
    Analysis of the Medicaid Application

    10:30 - 11:00, Terry C. Cox and F. Auston Wortman III
    1. Vocabulary
    2. Verifications
  4. “The caseworker’s job is to help get the application for benefits approved, right?”
    Overview of the Caseworker Review Process

    11:00 - 11:30, Terry C. Cox and F. Auston Wortman III
    1. Local Office Policies
    2. Interview
      1. Telephone
      2. Face-to-Face
  5. “Does my spouse have to go on government assistance when I go into the nursing home?”
    Allocation of Resources and Income

    12:30 - 1:15, Terry C. Cox and F. Auston Wortman III
    1. Income Allocation
    2. Resource Allocation
    3. Methods of Calculation
      1. Default
      2. Maximum
      3. Caseworker Determination
      4. Judicial Determination
    4. Intervention
  6. “They denied my application! How do I get this straightened out?”
    Request for Reconsideration of an Adverse Decision by the Caseworker

    1:15 - 1:45, Terry C. Cox and F. Auston Wortman III
    1. Filing the Request
    2. The Running Record
  7. “How can I be sure my Fair Hearing will be a fair hearing?”
    Fair Hearing Practice

    1:45 - 2:15, Terry C. Cox and F. Auston Wortman III
    1. Tennessee Rules of Civil Procedure
    2. Tennessee Rules of Evidence
    3. Tennessee Department of Human Services Administrative Rules of Practice
    4. Motion Practice
    5. Discovery
    6. Conducting the Hearing
    7. Preserving Issues for Appeal
  8. “They decided against me at the Fair Hearing; that doesn’t seem fair!”
    Appeals from Adverse Decision at Fair Hearing

    2:15 - 2:45, Terry C. Cox and F. Auston Wortman III
    1. Appeals to Chancery Court
    2. Timing Issues
    3. Conducting the Hearing
  9. “The nursing home is discharging my spouse! What do I do now?”
    Involuntary Discharge Hearings

    3:00 - 3:30, Terry C. Cox and F. Auston Wortman III
    1. Commissioner’s Designee
    2. Bureau of TennCare Administrative Rules of Practice
    3. Motion Practice
    4. Conducting the Hearing
  10. Ethics
    Ethical Considerations

    3:30 - 4:30, Terry C. Cox and F. Auston Wortman III
    1. Who is the Client?
    2. The Hierarchy of Goals

Seminar Summary:

The goal of this course is to provide an understanding of the legal environment in which appeals of Medicaid benefit denials are conducted and to offer a step-by-step guide through the basic elements of prosecuting an appeal. (see full course description)

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