Fair hearings allow recipients to appeal department actions that result in the denial, discontinuation, termination, suspension, or reduction of benefits. They are not for lodging complaints against providers. In this case, the petitioner filed a fair hearing that was “essentially a series of complaints about MTM’s handling” of her medical transportation benefits. Noting that this appeal was not about any denial of transportation or the amount of the benefit, ALJ Brian Schneider concluded: “petitioner’s complaints about how MTM handles her claims is simply not something that this Division oversees.”
This decision was published with support from the Wisconsin chapter of the National Academy of Elder Law Attorneys and Krause Financial.
Preliminary Recitals
Pursuant to a petition filed November 23, 2024, under Wis. Stat., §49.45(5), to review a decision by the Division of Medicaid Services (DMS) regarding Medical Assistance (MA) transportation coverage, a hearing was held on January 8, 2025, by telephone.
The issue for determination is whether the Division of Hearings and Appeals has authority to review petitioner’s claims.
PARTIES IN INTEREST:
Petitioner:
—
Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: Jessy Elledge
Division of Medicaid Services
PO Box 309
Madison, WI 53701-0309
ADMINISTRATIVE LAW JUDGE:
Brian C. Schneider
Division of Hearings and Appeals
Findings of Fact
- Petitioner is a resident of Marathon County who is eligible for MA.
- Petitioner has required out-of-area medical services. Claims have been made to MTM, the DMS’s contracted transportation provider.
- Petitioner filed this appeal, stating a litany of complaints about MTM’s handling of her transportation claims. She did not name a specific instance in which MTM failed to pay for a medical trip.
- After receiving the appeal, MTM staff reviewed claims made by petitioner. It found that all claims were paid, except that a mileage claim for an August, 2024 trip had not been paid because a trip log had not been filed (meals and lodging had been paid for that trip). MTM verified the trip and issued a payment for mileage on January 2, 2024.
Discussion
MA covers medical transportation of all types, including private vehicles driven by the recipient or a designated driver, called a “common carrier” in the parlance. The Wisconsin Administrative Code, §DHS 107.23(1)(d)2 reads: “Transportation of an MA recipient by a common carrier to a Wisconsin provider to receive MA-covered services shall be a covered service if the transportation is authorized by the county or tribal agency or its designated agency.” The law requires the transportation to be authorized before the trip. MTM is the Department’s designated agency, and it has set up a system where the MA recipient requests authorization prior to the trip to satisfy the legal requirement.
Petitioner’s appeal is essentially a series of complaints about MTM’s handling of her case. The problem is that it is an appeal to a hearing office that has no authority to act on the complaints:
The purpose of the fair hearing is to allow a recipient to appeal department actions which result in the denial, discontinuation, termination, suspension or reduction of the recipient’s MA benefits. The fair hearing process is not intended for recipients who wish to lodge complaints against providers concerning quality of services received, nor is it intended for recipients who wish to institute legal proceedings against providers. Recipients’ complaints about quality of care should be lodged with the appropriate channels established for this purpose, to include but not limited to provider peer review organizations, consumer advocacy organizations, regulatory agencies and the courts.
Wis. Admin. Code §DHS 104.01(5)(b). The Division of Hearings and Appeals can hear an appeal concerning the denial of MA transportation or the amount of reimbursement. However, petitioner’s complaints about how MTM handles her claims is simply not something that this Division oversees. I recommend that petitioner contact the telephone number on her ForwardHealth card to inquire how to make such complaints.
Petitioner did raise one issue that potentially could be reviewed. She testified that she asked MTM for a printout of all claims made by her, how much was paid, and whether any were denied. Petitioner, however, is the one making the claims for reimbursement. She should have a record of claims she made (she testified that she spent hours preparing for the hearing, but she did not have a record of her transportation claims). The MTM representative testified that all claims in the system were paid with the exception of the August, 2024 mileage one. It is the petitioner’s burden to come forward with specific issuances or non- or under-payment of claims. The fair hearing process is not a form of discovery. Petitioner should know what claims were filed and whether they were paid. Without specifics, petitioner’s appeal cannot be reviewed.
Conclusions of Law
The Division of Hearings and Appeals does not have jurisdiction to act on petitioner’s general complaints about MTM’s handling of her transportation claims.
THEREFORE, it is
Ordered
That the petition for review is hereby dismissed.
[Request for a rehearing and appeal to court instructions omitted.]
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