A Personal Account of a Medicaid Audit

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 DirectorsSouth 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



About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on February 22, 2013, in CCME, Division of Medical Assistance, Health Care Providers and Services, MCO, Medicaid, Medicaid Audits, Mental Health, NC DHHS, NC DMA Clinical Coverage Policy 8C, North Carolina and tagged , , , , , , , . Bookmark the permalink. 6 Comments.

  1. Electronic form-filling technology offers the capability to assure that all required information has been entered into a form before the form can be filed. Applying this technology could at least eliminate the nitpicking, though it would not eliminate investigations for fraud. The capability also exists to query for progressively more detailed inputs when certain answers are provided in the forms. Assuring completeness is not a technical challenge. The technology exists.

    The IRS has used “bands of reasonableness” in evaluating claimed tax deductions for a very long time. That technology could also be used to provide indications of possible overcharging or fraud.

    Applying this technology is neither rocket surgery nor brain science; rather, it is good management practice. Retroactive nitpicking, particularly based on incentive compensation, borders on thuggery. This results in a lose/lose/lose situation for providers, patients and society. One has to wonder who wins.

  2. I know Mr. Zeger referred to the recoupment auditing contractors getting paid by contingent fee as urban legend. However, I can assure you it is not urban legend. It is correct. The more “fraud” or money the contractors receive from health care providers, the more the company is paid.

  3. A poignant, eloquent, on target insight.
    Providers cannot be expected to endure such…
    The increasing dearth of providers renders debate over expansion of coverage as “sound and fury signifying nothing”.
    The contingency fee arrangement is not legend- — it is expressly authorized by law.

  4. Heather Griffin

    I knew who wrote this within the first two lines. Kudos to Geoff Zeger….you hit the nail on the head.

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