Monthly Archives: February 2013
Since the new MCO (managed care organization) system is SO new to the Medicaid system in North Carolina (as in since February 1, 2013), I though it would be prudent to explain what the in the heck is the MCO jurisdiction system.
An MCO is defined, generally, as: a health care provider or a group or organization of medical service providers who offers managed care health plans. It is a health organization that contracts with insurers or self-insured employers and finances and delivers health care using a specific provider network and specific services and products.
In NC, the MCOs are the messengers to the Division of Medical Assistance (DMA)…the middlemen…the ears of DMA. Instead of 100 separate LMEs, the 11 or so MCOs are supposed to create more of a state-wide, uniform Medicaid criteria. Now, I am not sure if the below image correctly depicts the jurisdictions of all the MCOs. It seems as though the MCOs’ jurisdictions change quite often, but the image below is the most current jurisdiction map I could find. Please, if someone else has a more current map, please share.
If you read today’s paper, you saw that more Medicaid fraud has been discovered. Good! Find the REAL Medicaid fraud!! Prosecute the providers who committed fraud! Recoup our wonderful State’s Medicaid funds that were dispersed unethically. But, in case there is any confusion as to what is Medicaid fraud, I have drafted the below correspondence to all Recovery Audit Contractors, and representatives thereof.
The Article to which I am referring states:
“Managers of a Mebane mental health facility pleaded guilty Wednesday to federal charges of Medicaid fraud, billing the state for services never provided.”
The key phrase? “for services never provided.” Yes, I agree, receiving Medicaid funds for services not rendered equals fraud. Go get ’em, Recovery Audit Contractors!!! But, please read my correspondence below explaining what is NOT fraud. And please, I respectfully request, please stop harassing the health care providers willing to service Medicaid recipients, who have NOT participated in any sort of fraud.
Dear Recovery Audit Contractor, (From Me)
Please note the meaning of “fraud.” Fraud is NOT providing desperately needed Medicaid services to Medicaid recipients and then:
- Having a legal guardian sign for a recipient’s service, but having the signature illegible and causing you to question the veracity of the signature; it is not meant to confuse you;
- Not (sorry about the double negative) having documents provided for mental therapy in the 16 first visits when documentation is not required; it is not meant to confuse you;
- Following the Division of Medical Assistance’s (DMA) Clinical Policy for the applicable year the service was rendered and failing to inform you that the policies changed over the years; it is not meant to confuse you;
- Providing the services needed for the Medicaid recipients with prior authorization and subsequently being informed that medical necessity is not met; this is not meant to confuse you;
- Submitting an electronic signature policy to DMA at the time services were rendered, but failing to look into the future and sending the same policy to you; it is not meant to confuse you;
- Submitting the identical treatment plans under one Medicaid provider ID number for two dates of services, receiving authorization from you for one and a denial from you for the other; it is not meant to confuse you;
- Signing a treatment plan as the provider, but failing to tell you I am the provider; my signature should read, “Dr. X, the provider of the services for which I just signed.” it is not meant to confuse you;
- Rendering services to my clients and not even submitting the reimbursement claims to you because I know you will deny the claims; I know it appears to you that I have less volume in business, not less confidence in you. Again, it is not meant to confuse you;
- Billing for John Doe Smith (name is anonymous) when John Doe Smith actually goes by the name “Doe,” which is reflected on all his medical records; it is not meant to confuse you;
- Billing a CPT code that, by definition, means that 45-50 minutes were spent, without specifically stating that the service rendered was 45-50 minutes in length; it is not meant to confuse you;
- Making any human mistake whatsoever, unlike DMA has never done (See the February 2013 audit), but still rendering medically necessary services to Medicaid recipients without just compensation because I love my clients; it is not meant to confuse you.
This bullet point is not comprehensive; there are probably 5 billion more items that do not constitute fraud. If you find yourself questioning whether a paperwork issue equals fraud, please do not hesitate to contact me.
All I request is this: Please, please, please stop harassing health care providers who accept Medicaid and do NOT participate in fraud. We, as North Carolinians need health care providers to accept Medicaid, otherwise, Medicaid recipients would have nowhere to go. The Medicaid card would give Medicaid recipients no health care. We, as North Carolinians, want to provide Medicaid recipients with quality health care. But if no one will accept Medicaid, Medicaid recipients will stay sick, stay disabled, and stay mentally ill.
Yesterday it became official.
The House, the bill passed 74-40. The Senate voted 31-16 to reject the programs.
New Federal 10th Circuit Case Decision Warns Health Care Providers: Never Miss an Appeal Deadline!…Or Else!!
Yesterday, the 10th Circuit Court of Appeals reminded everyone in the health care arena of the importance of appeal deadlines. More so than other areas of law, the Medicaid world imposes short appeal deadlines with drastic repercussions.
In a published decision, Full Life Hospice, LLC, v. Kathleen Sebelius, Secretary, United States Department of Health and Human Services, 2013 WL 674756, U.S. Ct. of App., 10th Cir. (February 26, 2013) (only Westlaw citation available), the 10th Circuit Court of Appeals stated that Full Life Hospice, LLC (Full Life) failed to request a hearing within 180 days after notice of the final determination for Full Life to repay Medicare reimbursements that the U.S. DHHS claimed were distributed above the spending cap.
Missing an appeal deadline will cause severe irreparable damage!!!
In Full Life Hospice, Full Life Hospice, a hospice care provider participating in the federal Medicare program, provided hospice care services to terminally ill Medicare beneficiaries and appropriately sought reimbursement for these services. In a later recoupment audit performed by a contracted agent of U.S. DHHS, (Sound Familiar?) the contracted agent demanded repayment of funds that it claimed were distributed in excess of a Medicare spending cap.
The Medicare Act allows for challenges to regulations such as 42 C.F.R. 418-309, but it establishes a specific procedure for bringing such claims. As is relevant here, this process can begin with a hospice provider’s challenge to the basis for a request for repayment made by an HHS fiscal intermediary.
A provider is required to file a request for such a hearing with the Board “within 180 days after notice of the intermediary’s final determination.” Id. § 1395oo(a)(3).
Because Full Life Hospice failed to request a hearing within 180 days, the 10th Circuit Court of Appeals found that it had no subject matter jurisdiction.
Now, here in NC, in Medicaid, the appeal deadlines are even faster.
Appeal a Tentative Notice of Overpayment: 15 days. The result of failing to appeal within 15 days? The Tentative Notice of Overpayment becomes a final decision. Period.
Appeal a DHHS Hearing Officer’s Decision: 60 days from the date of the decision. Failure to appeal within 60 days? Final Decision. Period.
What about a prepayment review, in which the statute does not allow an appeal? Wait until the 6 months pass and see whether you get off prepayment review? No. If you do, expect a letter of termination from the Medicaid contract. Be pro-active. Seek help. Health care providers ate currently appealing these prepayment reviews and, alternatively, seeking injunctions.
Bottom line: Do not miss a deadline.
One of my biggest complaints about the NC Medicaid auditing procedures is that services that were prior approved by the correct contracted company, now, at a later date, the prior authorization is being questioned by a, sometimes, different company which determines that medical necessity was not met…despite that medical necessary WAS met earlier.
In all my reconsideration reviews, I have made the “it’s not fair” argument for the health care providers to be told medical necessity was met, only to be told later that medical necessity was not met. I mean, can it get any more confusing? The only answer I received from DMA representatives was that this “look-back audit” is allowed by federal and state law.
I agree that audits are allowed by federal and state law. I do not agree that overturning past authorization of medical necessity is allowed by federal and state law.
N.C. Gen. Stat 108C-7(c), which regulates prepayment reviews, states, in pertinent part:
“For any claims in which the Department has given prior authorization, prepayment review shall not include review of the medical necessity for the approved services.”
Shall NOT include review of medical necessity. Shall not. Yet, in reconsideration reviews, I am, over and over again, arguing with Department representatives that this particular Medicaid recipient met medical necessity.
Shouldn’t someone tell the Department and the recoupment auditing companies that prepayment review shall not include review of the medical necessity?
Readers: I did not write the following blog. A gentleman emailed me his personal account of a health care provider undergoing a Medicaid audit. I asked for his permission to publish it and it was granted. (I apologize for any formatting issues.)
NOTE: The following is somewhat long but is a reflection of the recent topsy-turvy, sinusoidal, and duplicitous events in the NC Outpatient Mental Health setting…….
During the summer of 2012, while I was standing outside of a clinic where I contract waiting for my next client, a car rapidly pulled up and out jumped 4 stony faced people with briefcases and a purpose in their steps as they entered the clinic
It was an unannounced Medicaid audit.
Many clinicians and agencies knew these were occurring so it was not completely unexpected. At this particular free-standing private clinic which accepted Medicaid there was some anxiety (as any audit would produce) but we were pretty confident about our work – electronic medical records had fail safes for compliance, supervision occurred regularly, and the Clinical Coverage Policies for Medicaid were followed.
Over the next few months as the audit progressed a surrealistic Russian style bureaucratic nightmare occurred. Medical records were requested by the auditors and submitted by the clinic. CCME (Carolina Center for Medicaid Excellence) who was doing the audit would say ‘we didn’t get the records’ and be elusive and dodgy. Medical records were re-submitted – hand delivered. Feedback from CCME was that the Treatment Plans did not meet standards. The Treatment Plans were being developed in line with the posted Clinical Coverage Policy and they were also in line with the recommendations of one of the LME/MCO’s right over the county border but after much back and forth CCME continued to say they were not in compliance. CCME did not provide a clear indication of what compliance was nor did they provide a clear template for the Treatment Plans. (NOTE: The LME/MCO from the nearby county said the clinic’s Medical Records per their site review were at a 92.5% accuracy!!!)
Staff at the clinic worked diligently to cooperate with CCME but every attempt at cooperation was met with a shift of the carrot on the stick. Conference calls were scheduled, emails were written, repetitive requests for clarification were pursued without any success or resolve.
The clinic was then put on a “pre-payment review” meaning claims for services rendered were not paid until the records were reviewed and approved. ‘Pre-payment review’ is an unguided process that could take 30 days – the approval of records is based on unclear standards so any clinical services rendered were like the lottery – maybe they’ll get reimbursed if someone somewhere says documents meet some kind of unknown standards….or maybe they won’t get reimbursed at all.
Eventually, so much unproductive hoop jumping occurred and time was wasted that a deadline for acceptance by the local LME/MCO came due. Because of the delays by the CCME, the LME/MCO which went live on 2/1/13 said to the clinic ‘we can’t enroll you’ due to the ‘pre-payment’ status.
With only 3 days of lead time, over 100 clients – some of which were children in foster care or with PTSD or within the Juvenile Justice System – had to suddenly be terminated from treatment and referred to other agencies. Fortunately, the clinic will continue – contracted with the other county LME/MCO and accepting private insurance.
Was this top-down inefficient State bureaucracy? Was this effective Public Mental Health policy? Was there any consideration for how this would impact service provision and the clients? Was this purposeful – intended sabotaging of a clinic in order to reduce the number of providers within a community and save Medicaid dollars? Is this the CCME’s way of insuring ‘Excellence?’
I, and my colleagues who provide Public Mental Health services and who have weathered many pressures and changes, are not naive about accountability – we are ready to stand accountable and provide appropriate services with appropriate billing and documentation. I understand there are economic pressures at hand here but the current zeitgeist of audits, regulations and site reviews seems like a witch hunt and feels like a displacement for the past sins of others (http://www.inthepublicinterest.org/article/reform-wastes-millions-fails-mentally-ill). With the laser beam aimed at service providers – purposely geared to finding the smallest of errors in an effort to go ‘GOTCHA’ the zeitgeist is a culture of fear in order to insure accountability to DMA, CCME, DHHS, CMS, EDS, and the LME/MCO. Well what about accountability to our clients? Have policy makers forgotten about the clients in an effort to weed out the service provider playing field?
As a side note, it was rumored – and it may just be urban legend – that Medicaid auditors were paid based upon how much money they generated from the audit. If anyone has more information on this I would love to hear it – but at the community level it is understood that the contracted auditors were paid based upon how much money they were able to save Medicaid – how many claim denials they could find and how much money they were able to claw-back.
Wouldn’t this contractual arrangement be considered a kickback?….’the more money you save or make us the more you will get from us?’ Aren’t kickbacks considered illegal within the Medicaid and Medicare system?
Clinicians, Clinics and Agencies believe that there has been an INTENDED consequence with the tightening of regulations (such as CABHA and Medicaid Waiver) – the intention is the eventual reduction of the number of private agencies that provide outpatient Mental Healthcare. Both, agencies that do enhanced services as well as core services, are being purposely circuitously and indirectly liquidated. When looking at lists of agencies that accept Medicaid over time, there was a 50% reduction of agencies after CABHA. With the implementation of the Medicaid Waiver the list has dwindled even further. Initially LME/MCO’s have been accepting virtually all agencies that apply but it is anticipated that over the next year the bonsai tree will be trimmed even further with reviews of ‘outcome measures.’ More and more agencies will not be able to sustain. It is presumed that the final goal is to have a few large agencies contracted across the state.
Now, be advised that I have seen with my own eyes heinous service and billing improprieties in 2005 and 2006 and received backlash from profiteers when I called out inappropriate activities….so, I agree that it is necessary to set clear standards and hold providers accountable…HOWEVER, the zeitgeist is an over-rotation.
Let’s see how the pendulum swing, tightening of the noose and reduction of reimbursements is working….
One of the larger agencies that has satellite offices in 15 counties in the central NC area just closed two of it’s offices in 2 counties. In a different county where this large agency still has an office the pay for clinicians was cut, then cut again, then cut again, and a colleague of mine who works at this agency said that there were sweeping layoffis in her office. What is interesting is that many community clinicians believed this big multi county agency was one of the golden children that would sustain and still be standing while all the other ‘mom and pop’ or ‘pop up’ agencies were dissolved. Well, it seems like no one is immune anymore.
Another colleague of mine described how his multi county agency had radical re-structuring recently, specific Medicaid services were cut and the providers of those services were laid off, and there were across the board pay cuts.
Clinicians have no recourse either – ‘if you don’t like the pay cut then you can always try to find another job…wait…there are no other jobs since everyone else is closing so I guess you are stuck.’
On another side note, I recently head about a survey of private Psychologists who had been accepting Medicaid. The survey showed that over 40% of them intended to stop taking Medicaid clients due to the increase of regulations and requirements and reduction of reimbursements (all of which makes service provision cost and time prohibitive). Many of these surveyed Psychologists had over 8 years of experience – the intended consequence of reducing providers ALSO reduces your qualified and experienced professional base – these are the providers who know the clients and know the community and know the collateral resources.
I am aware of several private multi-county/multi-provider agencies that used to accept Medicaid clients but have stopped due to the cuts in rates and arduous regulations. What is interesting is that these private non-CABHA agencies provide excellent care, are preferred by clients, and ironically they bill a FRACTION of what CABHA agencies bill.
On February 1st a therapist from NC had an ‘opinion’ published in the Washington Post called:
“The risk of skimping on mental health funding”
Below is the link to this article which describes his frustrations with the Medicaid cuts in Southern Pines:
Since you may have to do a free ‘Register’ with the Washington Post online to see the article, here is an excerpt:
For mental health providers in North Carolina, 2013 marks another year of cuts to Medicaid reimbursement rates, which have declined steadily since 2008. States are responsible for a larger portion of mental health services than they are for physical services, which means mental health is hit hard by state budget negotiations. More than $4.3 billionhas been slashed from state mental health budgets nationwide since 2009, according to theNational Association of State Mental Health Program Directors. South Carolina, Alabama, Alaska, Illinois and Nevada are among the states that have had the deepest cuts.
The director of our clinic in Southern Pines, N.C., in the center of the state, has told me that this year’s cuts are likely to force us to close. Our facility offers mental-health and substance-abuse counseling to 75 to 100 clients a week, half of whom are 18 years old or younger. Typically, they are referred to us from child protective services, doctor’s offices or the local domestic violence/sexual assault agency.
When the events at the service delivery level are brought to policy makers’ attention, I deeply resent their disregarding platitude of “oh well….we know change is hard.” Well, it has been change (2001 divestiture and privatization), and change (2005 slashing community support), and change (2006 ValueOptions authorization policy changes) and change (2010 CABHA), and change (2012 Medicaid Waiver) and change (new billing and authorization systems such as Alpha and Provider Direct) and change (2013 Medicaid rates rates slashed 40% effective 1/1/13 then returned to prior rate on 1/23/13 with delays of payment for 1/13) and change (2013 CPT code changes and Medicaid rate and service time reductions)….You don’t know how many times I have had to say to clients “….I am sorry but there are NEW Medicaid regulations which will effect you in the following way…” You don’t know how many of my colleagues have said to me “….the agency where I was working closed….do you know who is hiring….”).
Furthermore, I resent the proverbial ‘pot calling the kettle black’ when Community Agencies, Individual Clinicians, and Private Practices accepting Medicaid are being scrutinized and audited to the point of being inoperable ALL THE WHILE there is waste and mismanagement at the top – DMA mismanagement (http://pulse.ncpolicywatch.org/2013/02/01/problems-identified-by-medicaid-audit-largely-result-of-nc-republicans-own-budget/), cost over runs with Computer Sciences Corporation (http://www.newsobserver.com/2012/06/17/2142627/state-contract-for-updating-computer.html), “structural flaws,” and more (http://www.wral.com/audit-mismanagement-costs-nc-medicaid-system-millions/12048026/).
I hope McCrory means what he says ( “We want to make sure that the money that’s supposed to help people is going to them, not to the administrative cost.”) and that ‘Medicaid Reform’ will have a positive result. I hate to be a ‘Negative Nick,’ but my fear (based on experience) is that if you squeeze on one side of the tube of toothpaste it gets smooshed (yes…a real word) to the other side….in other words, the ATTEMPT to reduce administrative waste may actually make its way down to the community level in the form of service and provider cuts. We shall see…..
I continue to provide services to Medicaid clients and IPRS clients through contracts with agencies, but it is unclear if I will be regulated out of the field. The Waiver continues….
Feel free to write back with your experiences, thoughts, and or comments.
Geoffrey Zeger, ACSW, LCSW
Many providers continue to accept Medicaid despite the fact that the state is conducting Medicaid audits, the providers feel harassed by the state, the providers are terrified that they have to pay back hundreds of thousands of dollars for health care services actually rendered to Medicaid recipients, the providers are forced to wait months post-services rendered to receive Medicaid reimbursements, and the reimbursements are so much lower than the overhead costs.
Why? Why do health care providers undergo so much emotional and financial strain to provide health care services to Medicaid recipients? I believe that health care providers who dedicate services to Medicaid recipients truly understand and believe that the Medicaid population deserves and needs quality health care. These providers understand that most providers will not undergo the mental and financial stress needed to meet all the Medicaid criteria and documentation. So these providers feel a sense of duty to Medicaid recipients.
And to those health care providers who accept Medicaid in NC: “Thank you.”
I heard a story today of a health care provider who deserves this “Thank you,” and more. When the Personal Care Services (PCS) criteria changed this past January 1, 2013, many of the provider’s clients no longer qualified to receive PCS under Medicaid. Did that stop the provider from providing the needed PCS? No. Is the provider paid for its services? No. But this provider was dedicated to its clientele.
So when 80-year-old Dorothy (obviously, I have changed the names), who suffers from late-stage breast cancer, dementia, and Rheumatoid arthritis was told that she no longer met the PCS criteria, she was terrified. But this provider continues, even today, to provide Dorothy the care she needs.
The provider is not reimbursed for helping Dorothy. But the provider feels a sense of duty. Do you turn your back on someone in need because the General Assembly changed the PCS requirements? Or do you continue to help the person you have cared for for so many years and hope that the government will somehow right the injustice?
Interestingly, this same provider is undergoing two Medicaid audits for a total of approximately half a million in alleged recoupments. The provider was forced to hire an attorney and defend the Medicaid reimbursements it has received for years of providing quality health care service to the Medicaid population. Instead of getting a “Thank you,” the state has audited and claimed that the provider must pay back almost half a million dollars, even though the provider provided all the services for which it billed.
Yet this provider, not only provides all the services for which it bills Medicaid, but when Medicaid drops Dorothy (and thousands of others) from the Medicaid program, this provider goes above and beyond its call of duty and provides services knowing that Medicaid will never reimburse it.
Maybe this provider should not be audited. Maybe the Medicaid system should be audited for all the services for which this provider is not paid. Or maybe this provider, and many others, deserve a simple:”Thank you.”
Remember the movie, “Invincible?” Based on the true story of Vince Papale, Greg Kinnear played the new football coach for the Philadelphia Eagles. The Eagles were so bad, at the time the movie took place, that, out of sheer desperation and drive to make the community notice the football team, Greg Kinnear opened tryouts in order to allow anyone to tryout for the professional football team. In comes Mark Walberg (playing Vince Papale). A bartender who plays football with his friends in an abandoned car lot. And, lo, and behold, Mark Walberg, who never played football in college, makes the professional football team and proceeds to make a difference in Philadelphia football history.
I tell this story because, much like the Philadelphia Eagles in 1976, the NC Medicaid system is at a very low period. And, similar to Greg Kinear’s plead to the citizens of Philadelphia, Governor McCrory and Aldona Wos have issued a Request for Information (“RFI”).
Click here for the actual RFI.
What is an RFI? Basically, an RFI is an invitation to the public for any ideas on how to fix our Medicaid system. Just like Greg Kinnear opening the professional football team to the public, McCrory is accepting anyone’s ideas on Medicaid. Similar to Kinnear’s experience, I’d wager that McCrory will have to wade through hundreds of dead-ends. Remember, in Invincible, hundreds of people tried out for the Eagles, but only one non-professional player, Mark Walberg, made the team. Even though only one non-professional person made the team in Invincible, that one person made a huge difference. The whole city cheered for Mark Walberg (Vince Papale).
So, I encourage everyone to participate in this RFI. If you have an idea to improve our Medicaid system, submit it. Who knows? Maybe we will find our own Vince Papale for NC Medicaid…
Submit by 2:00pm, March 15, 2013.