Who could I get to audit a claim from Medicaid Estate Recovery in Denver, Colorado? Some of the charges look wrong.

Perhaps Kasemcares.org could direct you. I just learned of this org on this site. Good luck, hope you get resolution soon.

Over 8 years, that could easily be 3 different funding cycles for several different programs. Some years there may be grants paying a part so it’s less. There won’t be consistency for community Medicaid like there is Medicare or for Medicaid room&board payment for NH residents.

If he was a “dual” - so on Medicare and Medicaid- Medicaid usually negotiates payment to zero out whatever Medicare doesn’t pay. So as there’s no co-pay due so no bills get sent. My experience is that the only way bills are sent out would be if the secondary (to Medicare) was a nonMedicaid payor like BCBS and the insurer requires the vendor to send a copy of the bill to the person insured.

Is there a house or other asset that the after death Medicaid Recovery could impact? So it makes sense to deal with Medicaid payments for his care?

Thank you for the information. It is just that there are line items in the accounting that don't make sense like it shows that there were 2 caregiving companies involved in his care and that was never the case. Another example is there is a huge difference between what one caregiving company charged per hour and what a different caregiving company charged later in time. Medicaid Estate Recovery gave me a list of all of the companies that supported my brother over the years, but I can’t prove anything. I have no bills that were sent to him. I think protesting the charges is a lost cause because I have no proof that they are wrong. I would have liked to see the charges as time went along rather than at the end of 8 years. I could have challenged them then.

Igloo - thank you for the detailed explanation. I learned something today

HMS is the outside contractor for about 1/3 of the states for MERP.

It’s a division of a very much much larger parent HMS that does other compliance/ match up work for CMS (Centers for Medicare & Medicaid) aka the Feds. Like if there’s a Stark Law case being worked up, CMS would be using data mined by the bigger parent HMS from within CMS and state Medicaid or other federal coshared programs to use for Stark prosecution. In my opinion, once states had to have a system to do MERP (due to changes in the law for Medicaid from DRA 2005), HMS was in a perfect spot to do a spin off smaller focused company to do MERP by individual contract with states who did not want to make merp a state employee project. HMS is a top notch company for data.  I’d imagine they have proprietary algorithms that they use for determining effectiveness. HMS - the parent co - is I think publicly traded. To me it’s important to know who your dealing with in situations.......

There are 2 main companies doing outside contractor MERP work, HMS & PCG. They both take a % of the recovery based on their individual states contract. 11-15% seems to be the range. HMS is the bigger player. Please realize that they are in essence debt collectors & their position may not / will not necessarily be in your or heirs interests.

Whatever is done by HMS or PCG must be within compliance for your states laws and administrative code. Like for example- say your elder continued to own a home although in a NH & on Medicaid- if your state allows for property costs paid by others to be removed from the Medicaid tally, then you as an heir or as executor can submit documentation of property costs that need to be subtracted to HMS. They are required to review & deduct if paperwork is in order. Now keeping property costs, etc is all on family to do and submit within whatever timeframe required. If you’ve gotten a NOI (Notice of Intent), there should be someplace within the questionnaire as to your indicating that you will be filing for exemption &/or exclusions to Recovery. The initial NOI must be responded to and done within whatever set timeframe required. This is pretty critical. They seem to be 90 days, and to me, it indicates to the recovery contractor what approach for them to take. If you do nothing, then after 90 days the tally is viewed as valid and it goes the traditional debt collectors playbook. But if you respond that you are filing exemptions, exclusions, opening probate, it’s a very different system. Then it enters the required cost benefit evaluation territory as well as being mindful of how probate runs in your state. 

Some Recovery aspects seem are not done by HMS but within a legal division of the states Health & Human Services Dept (HHS) or whatever is named the federal funding recipientfor Medicaid is called. Like if there’s a Secondary Payor involved, those seem to go to HHS legal dept rather than to HMS to deal with for Recovery. 

Imo the figures that you’ve gotten -if this was for a NH LTC Medicaid stay - are probably accurate. It’s all a set day rate for Room & Board that will comprise the lionshare of the medicaid tally. To me, spending time trying to shave off $ here & there from the overall tally of what medicaid $$$$ paid is a waste of time.

So what is this all about? Whats the concern? Is is that your parent was on Medicaid and continued to own their home and your trying to figure out what to do to enable you or heirs to keep the house? Or did the now deceased elder have a life insurance policy that has “estate” as beneficiary? or there’s another estate asset, like from an accident payout? Have you looked into exemptions and exclusions to MERP? & do you or other heirs qualify? Are you trying to be repaid costs you paid on a parents property or things you paid for their care? If this involves a house, does CO (State of CO & not contractor) have a guideline on property value that is used to determine cost benefit tipping point?

In my experience dealing with after death Recovery can be done but ideally will require an Recovery experienced Estate or probate atty and that someone in the family can document all expenses in detail and can afford all costs till recovery is resolved or property sold, and there’s a valid will and executor willing to do open probate unless something was set up before death to bypass probate. 

The letter is from HMS Estate Recovery Progam, Colorado Medical Assistance

If this was a NH Medicaid summary, there should be a set figure for daily room & board charge that Medicaid paid. What that to the penny amounts by state should be available from your state. Most states R&B are around $170 a day. So a year R&B at a NH would be $ 63K. Most of the professional medical charges - like MD, PT, podiatrist, etc - will be covered by Original Medicare. If they were instead on a Medicare Advantage system, you’d have to get the #s from the Advantage plan.

But if this was a Community based Medicaid program, that’s going to lots LOTS more difficult to figure out. Each aspect / vendor can have its own reimbursement schedule. I’m not sure it would be affordable to pay an atty or paralegal to even get into.....

Is all this about challenging the Recovery tally Medicaid has said is owed by the deceased Estate? If so, did you just get a NOI (notice of intent). And is it from the state or an outside contractor?

Thank you for your help. I’ll try it.

Unsurprisingly, certain law firms in Denver recommend that you use a lawyer :) At this point, you might want to try other avenues first.

The thing is, for now you're not even challenging the claim, you're just querying it and asking for verification. And I note that Colorado has contracted out its recovery programme to an organisation which, naturally, has every incentive to recover the maximum amount and may devote fewer resources to ensuring total accuracy.

So: you have reasonable questions to ask and are entitled to fair and accurate answers. I've ambled around the Colorado gov website looking for the right contact details for this purpose for twenty minutes now; and all I can say is if it were me I would be ready to resort to their instructions for "if you still need help" and contact the relevant County's Department of Human Services.