A massive backlog in Medicare and Medicaid applications and payments has spawned at least seven lawsuits that have been filed against the Illinois Department of Healthcare and Family Services, said attorney Chad Bogar, Managing Partner and CEO with sb2 Inc., a law firm specializing in Medicare/Medicaid Eligibility and Reimbursement cases.
The lawsuits have been filed for long-term care providers, the largest of which are Petersen Healthcare and Heritage healthcare, stemming from the current Medicaid application backlog and its impact on residents and providers.
To date, there is currently a backlog of approximately 7,000 cases pending Medicaid review. In Illinois, Medicaid covers seniors that do not have the ability to pay for long-term nursing home care, when they do not have the personal assets to cover care expenses.
"Federal law requires that states process applications within 45 days," said Bogar.
Bogar said it's an issue that has been going on for years, and providers are up against a wall because the majority of their clients are on Medicaid. Not only are applications stalled, but so are payments for beneficiaries that were already approved and providers are up against a wall.
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"Some providers have been waiting three years for payment and still haven't been paid. It was either this or go out of business. That's the reality of it."
The complaints allege that the backlog is due in part to a failure by the state agency to use an electronic asset verification program, or AVP, to determine eligibility for Medicaid in an appropriate amount of time.
"Congress passed a law in 2008 that clearly defines that states must implement an AVP system," said Bogar. "Not only did the state in this case not try to obtain resident information through AVP, they also did not try to access this information through secondary sources. The result is a serious backlog that is impacting facilities' ability to care for their residents."
Compounding the issue, Bogar said is a shortage of case workers to process the applications. The AVP systems can get the information like a credit check. Once info is found, caseworkers must apply it to applications. That's the theory. There aren't enough case workers at state level to do this, Bogar said.
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"This is a clear issue that needs quick resolution," Bogar said. "The state of Illinois needs to start using AVP and start shrinking this backlog of applications, as these elderly residents simply cannot afford to wait any longer."
He said they expect to file another suit next week, and are hoping things will move quickly. They have engaged the Illinois attorney general's office in order to reach a resolution faster. But if necessary, at the end of the year Bogar said they will file an emergency injunction demanding automatic approval of pending applications for potential beneficiaries as well as outstanding payments due providers.
HFN reached out to the Illinois Department of Healthcare and Family Services for comment, but the agency declined to speak on the matter.
Twitter: @BethJSanborn