NC Recoupment Agencies: Find the REAL Fraud!…Let Me Help:

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 full article

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.



About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on February 27, 2013, in Division of Medical Assistance, Fraud, Harassment, Medicaid, Medicaid Fraud, Mental Health, Mental Illness, NC DHHS, North Carolina, RAC and tagged , , , , , . Bookmark the permalink. 2 Comments.

  1. The law cannot cure stupidity, but it can “reward” cupidity.

  2. Nice reply, Ed:)

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