I randomly picked up Wednesday’s copy of “Indy” in a coffee shop. The title caught my eye, “The Legislature’s Disgraceful Two Weeks.” I mean, Wow. That’s quite a title! So, of course, I had to pick it up.
I turned to page 7 and read the “Block Obamacare” paragraph and almost choked when I read the paragraph. The statements written were patently untrue. Forgive my naivety, but isn’t there some sort of oath for journalists to at least attempt to state the truth?
I felt obligated to explain how the Indy failed to publish the correct facts.
First sentence: “The Affordable Health Care Act would extend Medicaid (government health insurance for poor people) to 500,000 North Carolinians who don’t currently qualify – at essentially no cost to the State.”
No cost to the State??? Seriously? Where did these facts come from??? Reality: According to an economic study in the New York Times, should North Carolina expand Medicaid, between 2014-2019, North Carolina would have to contribute approximately $1.029 Billion. Yes, Billion!!! If you think $1.029 billion is “essentially no cost,” please send me a check for a few million. Make it out to my name please.
Second sentence: “Nonetheless, Senate and House Republicans have said they don’t want the money.”
What? They don’t want the money? The sentence makes it sounds like the federal government is passing around a basket full of money and asking the states to take what they want. Not only is this sentence incorrect, it is misleading. There is no free basket full of money for everyone. And no one in the General Assembly (I feel confident this is correct, although it has not been corroborated) is refusing free money.
The choice to not expand Medicaid is predicated on a plethora of reasons. One reason off the top of my head, is that, according to the recent audit conducted on DMA, yearly, DMA spent approximately $648.8 million on administration costs. Proponents of Medicaid expansion have said that Medicaid expansion would create jobs. Guess where? DMA. Let’s ADD to the administration costs instead of reeling them in….Really???? This is similar to the mentality I had as a teenager: I know I’m doing something wrong, but unless my parents find out, so what?
Third sentence: “The bill to block the expansion is en route to the House with the backing of Gov. Pat McCrory.”
Ok, that was the only sentence somewhat true with one large difference. In reality, Gov. McCrory has been extremely hesitant to rush the decision of whether to expand Medicaid. He urged lawmakers not to rush.
So after reading the paragraph preceding the article, I was terrified to actually read the article. But much like a train wreck happening in front of you, I couldn’t resist.
My favorite line: “It’s long been apparent that Republicans should have no credibility on the question of fiscal prudence.”
Once I read that sentence, I laughed out loud. Obviously, this journalist suffers from extreme parochial vision and has made the topic a “Republicans v. Democrats” debate. People, who cares what political side you are on? Medicaid recipients deserve quality care and enough health care providers to care for the entire Medicaid population (currently around 1.5 million in North Carolina). Right now, in North Carolina, Medicaid recipients cannot find physicians, psychologists, dentists, or specialty physicians willing to accept Medicaid patients.
Fix that!!
Enable the 1.5 million North Carolinians, to whom we owe a duty to provide health care, to receive quality health care. Personally, if I were on the cusp of receiving Medicaid, and I knew that, through Medicaid expansion, I could get the Medicaid card, but not find a doctor willing to accept me (or if I found one to accept me that I wouldn’t get all the tests or procedures that someone with private insurance would undergo), I would choose to say, “No, to unequal health care.”
Click below to see my interview on WRAL News!!!
Knicole C. Emanuel represents health care providers with Medicaid issues, such as prepayment reviews and Tentative Notices of Overpayments. A client, Dr. April Harris-Britt, has received a termination of Medicaid letter. Ms. Emanuel is appealing the notice. If Dr. Harris-Britt cannot accept Medicaid hundreds of Medicaid recipients will need to be discharged from mental health services.
Medicaid eligibility. Just the phrase itself raises so many questions:
Am I eligible? Would I be eligible if NC expanded Medicaid? If NC does not expand Medicaid, does that mean I don’t have health insurance? What exactly is the income limit for a family of 4?
The Medicaid system, like our tax system, is esoteric. So, the purpose of today’s blog is set out some much-needed facts.
First, Medicaid eligibility, as of today, can be found in an extremely detailed, yet hard to understand, chart on the Department of Health and Human Services‘ (DHHS) website. Click here. But don’t say I didn’t warn you.
Under the federal health care law, should NC choose to accept the federal dollars, eligibility for government-backed Medicaid may be expanded in 2014 to anyone making below 138 percent of the federal poverty level. Here’s who would qualify:
Family size: Income level
1 person: $15,414
2 people: $20,879
3 people: $26,344
4 people: $31,809
So there is it: The Medicaid eligibility requirements currently and if NC accepts federal dollars.
It is important to note that, on Tuesday, February 12, 2013, Governor McCrory endorsed a measure to prevent major components of the federal health care law from taking effect in North Carolina. Merely hours after McCrory’s announcement, the measure won easy approval in a House committee. The full House will consider the legislation quickly.
I will devote another blog to the effects of reform versus expansion. Today, I only wanted to get the eligibility requirements out.
Very rarely in the Medicaid arena will a health care provider be able to choose to advance to the Office of Administrative Hearings (OAH) without first visiting the Hearing Officers at the Department of Health and Human Services (DHHS). However, if ever given the choice, in the famous words of the Monopoly Man, “Go Directly to OAH! Do not pass DHHS! Do not collect your $200!”
When does a health care provider get this choice?
Never after receiving a Tentative Notice of Overpayment. But when a health care provider is placed on prepayment review and, subsequently, receives a Termination of Medicaid Contract notice, the provider may choose to (a) appeal to DHHS within 15 days; or (b) appeal to OAH within 60 days.
Why OAH?
1. Going straight to OAH skips a tedious procedural step (the reconsideration review):
Since I have practiced Medicaid law, I have never seen a decision from a DHHS Hearing Officer with which I agreed. Of all the DHHS decisions I have received on behalf of my clients, I have appealed 100%. Now, I am not saying that health care providers should not appeal if the only choice is DHHS. In fact, I strongly encourage the exact opposite. Because appealing to DHHS, in most circumstances, is just the beginning. Once the appeal is heard by a DHHS Hearing Officer and a decision in rendered, then a provider can move on to appeal to OAH. But, when given a choice between DHHS and OAH, always pick OAH because, basically, going straight to OAH allows the health care provider to skip a step.
2. Going straight to OAH costs less in attorneys’ fees:
Again, because going straight to OAH allows the health care provider to skip the reconsideration review at the DHHS level, attorneys’ fees are less.
3. Going straight to OAH appoints an Administrative Law Judge (ALJ):
If given the option between a DHHS Hearing Officer and an ALJ (not employed by DHHS), which would you chose to be the objective truth-seeker? I am in no way insinuating that the DHHS Hearing Officer is biased. I, personally, would just choose the person to hear my case who was not employed by DHHS. Plus, for the most part, ALJs are more sympathetic to Medicaid recipients and providers.
4. Going straight to OAH appoints an Attorney General (AG):
What? This is a good thing??? We WANT an attorney against us? Yes. Until the Medicaid recoupment appeal gets to the OAH level, there is no attorney on the state’s side. Which means no settlement can be discussed. Once an AG is assigned, the likelihood of settling skyrockets. The AGs understand the Medicaid rules and the benefits to settle. Thus, having a knowledgable attorney on the state’s side is extremely beneficial.
Despite all these great reasons to “Go Directly to OAH! Do not pass DHHS!,” inevitably, health care providers will normally not be able to skip DHHS. My advice? Appeal, Appeal, Appeal. And once you get the Decision from DHHS? Appeal, Appeal, Appeal. The decisions only get better once you receive that first DHHS decision.
Similarly to the “Boy Who Cried Wolf” from Aesop’s fables, The state Medicaid auditors are crying, “Fraud.”
Remember in Aesop’s fables, the boy repeatedly cried, “Wolf.” Each time the villagers ran to help the boy, only to find the boy laughing at the villagers’ naivety. After numerous “fakes,” a wolf truly came to hunt the boy’s sheep. While he feverishly cried, “Wolf” at the top of his lungs, the villagers were nowhere to be found.
Now it seems that the state’s Recovery Audit Contractors (RAC) are mimicking the actions of the boy who cried wolf. How do I make this literary analogy between the boy who cried wolf and the RAC’s actions? Because the purpose of the RACs were to detect fraud. The federal government required all states to implement a state-wide RAC program to detect fraud, not innocent paperwork mistakes.
Fraud is defined as: an intentional deception made for personal gain or to damage another individual.
If you saw WRAL 6:00 news Friday, then you saw one of my clients who had been placed on prepayment review. What a horror story!! My client noticed last August (2012) that the State stopped paying her Medicaid reimbursements. Now six months later she received a notice that her Medicaid contract was being terminated. The reasons were unclear, but the statute under which the State may, first, place a health care provider on prepayment review, and, subsequently, terminating the health care provider’s Medicaid contract was drafted to detect Medicaid fraud.
However, my client did not commit fraud. All the mental health services for which she was paid, were actually rendered for Medicaid recipients. The alleged problems? Innocent paperwork errors, or, in some instances, errors on the part of the RACs.
For example, DMA Clinical Policy 8C requires the service notes to indicate the duration of the service. However, for most of the Outpatient Behavioral Health services, the CPT code, by definition, states the duration. If a provider bills for 90816: the services was 20-30 minutes. Therefore, by the provider writing the CPT code, the provider stated the duration of the service. Yet, the RACs are citing lack of duration written on the service notes, despite the CPT codes providing the duration.
Why? Why would the RACs proceed to audit Medicaid claims crying “Fraud” for these innocent paperwork errors, or in the case of the lack of duration of services, not even errors on the part of the provider?
Good question. I do not have the answers. However, I have theories:
1. Lack of Supervision/Confusion: The RACs have these government contracts to audit Medicaid payments, but the state is not supervising the audits. Basically, the state created these RACs and then turned them loose. The lack of supervision by the state is creating a free-for-all. The RACs are trying to do the jobs for which they were hired, but without guidance.
2. Incentive: Interestingly, RACs are reimbursed by a contingent fee. Meaning, if the contracted companies recover more money from the health care providers, the contracted company received a higher reimbursement.
Now because the contracted companies are paid more if they recover more, does that create a bias? A perceived bias? Certainly a desire by the contracted companies’ employees to recover more Medicaid money; after all, the employees are only human.
Since these RACs have been implemented, many, many providers are having to defend themselves from the allegations of, “Fraud.”
I wonder if crying,”Fraud” so many times, like the boy who cried wolf, will create a sense that maybe fraud truly is not being found. So when the RACs find true fraud, will anyone come running?
Today, I had a fascinating discussion with a gentleman (who will remain unnamed. I will call him Joe). (BTW: The veracity of the information in this blog is not based on my first-hand knowledge, it is based on Joe’s). For years, Joe owned a nursing home ( he recently sold it). He explained that he never accepted over 20% Medicaid clients. His friend, Bill (also unnamed) also owned a nursing home. Bill accepted 100% Medicaid clients. So let’s explore the differences between the two nursing homes.
Joe’s: The nursing home was brand new. Joe had the building built with state-of-the-art medical access (pre-wired for medical equipment, etc.). The staff was exceptional. The beds were the kind that you can lay down or sit up; the beds also vibrated at certain times of the day to prevent bed sores. Each room had a television. The cafeteria provided an array of healthy foods.
Bill’s: The nursing home was located in an old concrete building. The nursing home met all the minimal requirements in which to meet the criteria to receive its Certificate of Need (CON). There was staff. There were beds, but not the movable type, just basic single beds. There was food. Residents and family of residents complained often about the living conditions, but the nursing home met the state’s minimum requirements.
Joe’s: The nursing home was profitable as long as it kept the number of Medicaid recipients to a minimum. Many times Medicaid recipients were turned away.
Bill’s: The nursing home was profitable as long as he kept his staff to a minimum and quality of food, beds, cafeteria meeting the minimum requirements.
What I extracted from Joe’s comparison between the two nursing homes, was that Medicaid recipients, for the most part, were receiving less quality care than those with private insurance. Fair?
You have to ask yourself why was Bill’s nursing home profitable with all Medicaid clients? Because the Medicaid clients were housed in a nursing home that only met minimum standards. Bill’s nursing home was a concrete block building. There were neither TVs nor upgraded medical equipment. By keeping his overhead at a minimum, Bill was able to make a profit off Medicaid clients.
On the other hand, Joe’s state-of-the-art nursing home had to limit the number of Medicaid recipients in order to maintain a profit.
Why does Medicaid pay so little to health care providers? With all the money going into Medicaid budgets/funds, why can’t more be allocated to paying higher reimbursements to health care providers? It seems to me that, if you agree that Medicaid is a needed program, you would agree that the Medicaid recipients should also receive quality health care. Personally, I would much rather end up in Joe’s nursing home rather than Bill’s.
Despite, Governor McCrory’s hint a few days ago toward Medicaid reform, not Medicaid expansion, today, on Facebook, I noticed a virtual Petition circulating. The Petition is asking Governor McCrory to please expand Medicaid. I’ve copied the Petition’s language below, as well as, provided you a link in case you want to sign the Petition. For ease of reading this blog, I have italicized the actual Petition.
By Action NC (Contact)
To be delivered to: Pat McCrory, Governor
Gov. McCrory, the power to fundamentally change the health care system in our state is in your hands. By expanding Medicaid, low-income North Carolinians will have access to health coverage, and there is potential to undo the profound health disparities in our state.
As it stands, North Carolinians who are uninsured are likelier to develop serious health complications or die younger from diseases that are all too often preventable. By gaining health insurance through Medicaid, we would add health coverage for more than half-a-million North Carolinians within five years who otherwise would remain under insured.
We urge Gov. McCrory to implement the Medicaid Expansion for low-income individuals under the Affordable Care Act so that all of our state can remain healthy and strong.
End of Petition.
Period. That’s it. The end. That’s the extent of background information provided before the Petition expects, or the authors of the Petition, expect people to electronically sign their names. And people have. 4512 people have signed the Petition….and climbing.
Shoot, if that was all the research I did (merely reading the Petition Background) I would probably sign it too. I mean, who doesn’t want “half-a-million North Carolinians” to get health care coverage? Who wouldn’t want “all of our state to remain healthy and strong?” I want half-a-million of North Carolinians to have health care coverage!! The difference is that I want the health care coverage to be as good as private insurance. So, sadly, we need to be realistic.
Readers: BEWARE! Expanding Medicaid will not make our state healthy and strong. Expanding Medicaid will not provide half-a-million NC residents quality health care (Note, I said quality health care, not health insurance….HUGE difference).
I think what upsets me so much about this Petition is that it is propaganda. It appeals to emotion, not facts. Reading the Petition incites emotion. Most humans, I hope, want to help other humans. If all I did was read the Petition, the Petition would bear my name. So, in a way, the Petition is only disclosing partial facts. Hence the definition of propaganda.
Propaganda is defined as:
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Noun
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Historically, the Nazis were the best with propaganda. TThe Nazi’s used propaganda to incite anger toward Jews and create a feeling of superiority in whites. As you can see, propaganda is not always a good thing. To me (maybe not the Webster’s definition), propaganda is any misleading political information that incites emotion with zero basis in fact.
According to the Petition, “there is potential to undo the profound health disparities in our state.” (If we expand.) Wrong.
If North Carolina accepted the expansion of Medicaid, yes, approximately 700,00 more North Carolinainas would have health care coverage under Medicaid. However, the “profound health disparites in our state” will be exacerbated.
Let me explain:
Already today, approximately 60% of physicians and health care providers in North Carolina do not accept Medicaid. What does that mean? Why is that important? If you have Medicaid and cannot find a physician to provide care to you, what good is the Medicaid card?
If a health care provider does accept Medicaid, that health care provider is being compensated at a severely lower rate than what a Blue Cross would compensate. Just thinking logically, do you think that health care provider is providing equal service to the person with Blue Cross versus the person with Medicaid?
Fact: Some Medicaid recipients are unable to locate any health care provider to provide health care to them unless they drive hours to a non-rural county.
Question: Logically, if we add 700,000 more North Carolinians on Medicaid, do you think that the Medicaid recipients will have an easier time or a harder time locating physicians or health care providers?
The fact of the matter is that the Petition SHOULD have stated, something to this effect, sign here if you want more people to be eligible for Medicaid, but less Medicaid recipients to receive quality health care. My question is doesn’t Medicaid recipients deserve quality care?
If you agree, sign here:
Medicaid recoupments actions have skyrocketed in the past year. But, in the upcoming year, a new group of health care providers will be targeted for recoupment actions. According to the February 2013 Medicaid Bulletin, health care providers that serve the Medicaid population with inpatient and outpatient hospital care, long-term care, laboratory services, x-ray services, and specialized outpatient therapy claims.
DMA has partnered with HMS to become the 2nd RAC vendor for North Carolina.
What is a RAC?
In the most simple terms: A RAC is an entity hired by the State to review Medicaid payments to health care providers and, subsequently, recoup the Medicaid overpayents for the State.
This past year hundreds of health care providers in the mental health fields, personal care services, and outpatient behavioral health services have received Tentative Notices of Overpayment. Some Notices claim repayment amounts in the millions.
Well, now, on to the hospitals…Imagine how large hospital recoupments will be….
The most common statements I hear from health care providers when they are going through Medicaid audits is “I did not know THAT was required,” or “No one told us that we had to do THAT,” or, my personal favorite, “I called DMA and they told me we were doing THAT correctly.”
Tip #9:
First, if you call DMA, document the conversation in writing. Get the DMA representative’s name, title, and summarize the phone call in a safe place. Then write a letter to DMA summarizing the information you received.
Write something like this: “Per our phone conversation [DATE], you stated that [insert explanation, i.e., you stated that electronic signatures complied with NC Medicaid policy, if I take the following steps…]”
If you take this precaution, filing a note of the conversation and following-up with a letter, the you ensure that DMA cannot, later, deny the conversation. Remember, with oral conversations, no one remembers the conversation exactly the same.
Tip #10:
All health care providers, I venture to guess, at some point, needs to call DMA and ask a question. If so, follow Tip #9. But if you find that you or your employees often have questions, BE PROACTIVE.
Do not wait until the Medicaid audit to say, “I did not know THAT was required.”
How to be proactive? EDUCATE! Yourself and all your employees!
One of two ways:
1. Go on the DHHS website and find out when the State is giving educational seminars on Medicaid rules. And go to as many seminars as possible. While there, ask numerous questions;
or
2. Contact a Medicaid attorney (This is not an advertisement for myself, although I have done this for providers, but, please, research other Medicaid attorneys.) and have the Medicaid attorney come to your main office and give a presentation on Medicaid rules. If you go this route, make sure the Medicaid attorney understands what type of Medicaid services you provide, even better, tell the Medicaid attorney your specific concerns regarding your practice.
The upside about attending DHHS seminars is that the seminars are free. The upside of hiring a Medicaid attorney to come to your office, he or she can physically review some of your practices’ documentation for possible common mistakes.
Regardless, whatever you decide, do not do nothing until you received the Tentative Notice of Overpayment. It’s too late then. Be proactive in education.
