Medicaid Provider

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Administrative Salaries: Management fees paid to an individual who is not actively engaged in the day-to-day activities of a nursing home are not a cost of doing business, nor are they an expense related to the conduct of nursing home activities. Decision: 8 N.J.A.R. 463

Denial of Reimbursement: A Medicaid provider is not entitled to a hearing prior to a denial of reimbursement. Decision: 3 N.J.A.R. 351; When no agency policy exists either authorizing or precluding a Medicaid provider from performing a service and it does so at the request of a physician it should receive payment for the labor involved. Decision: 4 N.J.A.R. 278

Hospital Reimbursement: A hospital's failure to sustain its burden of proof to demonstrate additional costs for policy finance benefit costs, fiscal costs and plant costs results in a denial of change in established Blue Cross reimbursement rates. Decision: 4 N.J.A.R. 076

Impact Increment: In a proceeding to recoup excess impact increments, a Medicaid provider should be able to set off against the claim of the Division of Medical Assistance any valid claim for impact increments it may have. Decision: 1 N.J.A.R. 240

Notice: A series of letters to a hospital constitutes sufficient notice that it was being denied Medicaid reimbursement. Decision: 3 N.J.A.R. 351

Overpayments: Recovery of Medicaid overpayments with interests will not be barred by equitable estoppel where no showing was made that an officer of the State, conscious of the State's true interest and aware of petitioner's misapprehension stood by while the other party acted in detrimental reliance. Decision: 8 N.J.A.R. 217; Interest on unintentional overpayments from the Division of Medical Assistance and Health Services accrues from the date the overpayment was made and continues until it is repaid. Decision: 8 N.J.A.R. 195; Interest payments on Medical Assistance overpayments are tolled in the event the State does not give the provider notice of such overpayments within 180 days of a filed audit. Decision: 8 N.J.A.R. 195

Personal Liability: While New Jersey law will not permit the piercing of a corporate veil in the absence of fraud or injustice, Federal case law governs the administration of Federal programs and will allow the piercing of a corporate veil to present circumvention of a statute or advoidance of a clear legislative purpose. Decision: 8 N.J.A.R. 217

Rate Setting: The rate setting procedures for the establishment of Medicaid reimbursement rates are entitled to a presumption of reasonability; a presumption which is not overcome when no specific expert testimony on the question is presented. Decision: 8 N.J.A.R. 231; The rate setting methodology used by the Division of Medical Assistance and Health Services is entitled to a presumption of reasonableness and it is the provider which bears the burden to demonstrate otherwise. Decision: 8 N.J.A.R. 561; Increasing utility costs do not constitute an unusual situation under N.J.A.C. 10:63-3.20 and thus would not support a change in Medicaid rate setting guidelines. Decision: 8 N.J.A.R. 475; The Division of Medical Assistance and Health Services, and not the Department of Health, is alone responsible for the validity of Medicaid rates. Decision: 8 N.J.A.R. 389; The Division of Medical Assistance and Health Services is not bound by a recommendation by the Department of Health to revise Medicaid reimbursement rates since the Department's statutory role is limited to assisting the Division with the development of reimbursement rates. Decision: 8 N.J.A.R. 389

Suspension: Authority to suspend Medicaid status on grounds of moral turpitude requires the prior approval of the Attorney General. Decision: 5 N.J.A.R. 430; N.J.S.A. 30:4D-11.1(a) vests the Division of Medical Assistance and Health Services with the authority to suspend persons from participating in Medicaid independent of any licensing board. Decision: 8 N.J.A.R. 517

Unusual Costs: Increasing utility costs do not constitute an unusual situation under N.J.A.C. 10:63-3.20 and thus would not support a change in Medicaid rate setting guidelines. Decision: 8 N.J.A.R. 475