Federal judge: Primary-care doctors don’t have to pay back ‘Medicaid bump’ funds
The primary-care doctors filed the lawsuit in the
Doctors used the
To qualify for the enhanced Medicaid reimbursement rates in 2013-14, doctors had to either be board-certified in family medicine, pediatrics or geriatrics, or if they were not board-certified, at least 66 percent of the claims they billed -- the number of claims, not the monetary value -- had to be for evaluation and management services or vaccinations, not labs or imaging tests.
But in 2015, CMS sent notices to 118 Tennessee doctors telling them they didn't meet those requirements and would have to pay back the incentive money. Thirty-three of them appealed.
The 21 doctors who opted to file suit argued that CMS was discriminating against them because they provided diagnostic labs or imaging in-house -- which they did because such services weren't readily available to the patients they served, either because they required a long drive, or because patients lacked the resources to get to them. Some of them said they assumed the 66 percent applied to the monetary amount of claims, not the actual number of claims filed.
On
"We were a full-service clinic" in a neighborhood where many residents would have had trouble finding or getting to other lab services, said one of the plaintiffs, Dr.
Before his King's retirement, he operated a private family practice in Mechanicsville, one of
"To me, the government is trying to say if you're a patient in this area, you don't need the same services as another person gets," he said. "And yet they want physicians to serve in those areas."
CMS's attempt to "claw back" the money came after a federally mandated audit in
Law firm
"The risk of having to repay funds we received years ago forced us to end some of the steps we took to expand access, such as hiring an internal medicine specialist to improve our treatment and prevention of chronic illnesses such as diabetes," said Dowling, who said he initially had to lay off one of the bilingual nurses and couldn't renew the diabetes expert's contract.
Now, Dowling said, he may be able to reinstate those services.
The government has 30 days to file an appeal to the court ruling.
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