June 2013

Medicaid “outlier” claim was timely filed due to mutual action amending terms of contract.

Care Management Organization

Peach State Health Plan, a private Care Management Organization, acting as agent of the Department of Community Health, denied the Medical Center of Central Georgia’s (“MCCG”) request for “outlier” payments (i.e., payments for unusually expensive services) for untimeliness.  By contract, outlier claims must be made within three months of payments on “inlier” claims. The confusion […]

Medicaid “outlier” claim was timely filed due to mutual action amending terms of contract. Read More

Teacher is warned to avoid further unethical conduct.

Educators

The Professional Standards Commission’s decision to sanction Petitioner’s teaching license was modified from a two-year suspension to a warning.  The basis for the sanction was Petitioner’s plea under the First Offender Act that resulted from her failure to return a rental vehicle.  Petitioner admitted the wrongdoing and expressed remorse.  Under the circumstances, a two-year suspension

Teacher is warned to avoid further unethical conduct. Read More

State must provide medical services to eligible children to improve or maintain a child’s health in the best condition possible.

Health Law

DCH could not reduce a GAPP recipient’s skilled nursing hours beyond what is medically necessary to ameliorate his condition.  The Court gave great weight to the testimony of Petitioner’s personal physicians, who testified that a reduction in skilled nursing care would be hazardous to the child’s tenuous health.  The Georgia Medical Care Foundation misconstrued the

State must provide medical services to eligible children to improve or maintain a child’s health in the best condition possible. Read More

No recoupment of funds where Department coordinator failed to amend ISP.

Health Law

Petitioner, a personal care home, appealed the decision of the Department of Community Health to recoup a year of payments for services to a Medicaid recipient.  The Department’s decision was based upon Petitioner’s failure to adhere to the recipient’s individual service plan (“ISP”).  Judge Baxter reversed the recoupment decision, finding that Petitioner provided all of

No recoupment of funds where Department coordinator failed to amend ISP. Read More

OSAH Website

Court News

OSAH Website: On OSAH’s website, located at www.osah.ga.gov, visitors can access various resources. First, and most importantly, parties can obtain the decision in their case on the website. Second, the public can access court calendars, searchable by date and judge, docket number, or agency. Third, parties and interested persons can access OSAH procedural rules, general

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