DMA Says, “It Wasn’t Me.”

Call up DMA. Ask about an issue. I bet DMA will pass the buck.  I call this the “It’s not me” disease.  Apparently, DMA has been infected.

Today I had a reconsideration review at the Division of Medical Assistance (DMA). This was a case in which DMA claimed my client was overpaid with Medicaid funds because of alleged documentation errors. My client was audited May of last year, never heard any results, then almost a year later, received a Tentative Notice of Overpayment stating that he owed DMA X dollars.  He came to me and we appealed the Notice.

For the most part, today’s reconsideration review was similar to past reconsideration reviews:

  • DMA cited my client for not having prior authorization when prior authorization was not required under DMA Clinical Policy 8C (Prior to January 1, 2012, the first 26 visits with a child were unmanaged in Outpatient Behavioral Therapy (OBT), thus not requiring prior authorization);
  • DMA cited my client for inappropriate referrals when the Medicaid recipient was an adult (Adults can self-refer for OBT);
  • DMA cited my client for failure to produce assessments when assessments were not required;

All that was normal. As usual, my client was cited for reasons inconsistent with Medicaid policy and regulations.

DMA’s inability to audit a health care provider in accordance to Medicaid policy and regulations was not why today’s reconsideration review was odd.

No, today was odd because the person DMA sent to represent DMA was a woman who did not conduct the audit, had never reviewed the audit findings until sitting in the reconsideration review, was completely unprepared and was, obviously, confused by the entire process of a reconsideration review.

DMA’s rep (we will call her Jane) introduced herself to me as a “DMA Hearing Specialist.” What? What is that?? I asked whether this was a new position, to which she responded, “Yes,” and informed me that she was only hired by DMA last August. I asked whether there were other “DMA Hearing Specialists.”  She told me there were 3 others. This was news to me.  I had never heard of a “DMA Hearing Specialist.”  But in my head, I thought, “Good. A specialist. At least she will know what is going on.”

Wrong again.

We went to the first Medicaid recipient at issue. (This was a recipient who was not my client’s client.  For reasons not important here, it was mis-billed, and my client had already returned the money to the appropriate provider). Jane, however, had not been informed of this detail.  First she stated that my client had provided all the required documents because under the section, “Reasons for Denial,” “ABCDEFG” was marked (meaning every reason provided was marked.) So the hearing officer asked whether this meant there was no issue for this recipient. Jane said “I guess so,” and “Maybe.”

Once the hearing officer asked again, Jane finally said, “Oh, never mind, the ABCDEFG means that no documents were provided. We needed everything.”

Once we cleared up that ambiguity, we informed the hearing officer that this recipient was not a client of my clients and that the money had been returned.

Now, it is important to note that at the beginning of the reconsideration review, Jane produced a summary of all claims findings from my client’s audit, as well as, a detailed explanation of all denials. Shocked, I requested copies (because my client had received zero information as to what the document deficiencies were prior to the reconsideration review).

In the summary (that we had not received until the date of the reconsideration review), on page 3, first paragraph, there was a detailed description about the auditor speaking to my client about the mis-billing, his subsequent return of the Medicaid funds, and the auditor’s review of financial information proving the fact that my client had returned the funds.  That audit occurred May 2012.  Now, today, we sat in the reconsideration review (March 2013) and my client was being cited for the very same issue that he proved in May 2012.  In other words, despite my client’s explaining the situation to the auditor and providing financial records to prove that he returned the funds, he STILL sat there today and had to explain it again and had been cited for the very reason he already proved.

When I asked Jane why we were still discussing an issue that had been resolved almost a year ago, she told that she did not conduct the audit.  She was just told to come to this reconsideration review and she was not to blame. (It was someone else at DMA). Why was that “someone else” not attending the reconsideration review?

The “it wasn’t me” theme is WAY too prevalent at DMA. When someone complains about a Managed Care Organization (MCO), DMA says, “It wasn’t me.” When an audit is incorrectly conducted DMA says, “It wasn’t me; it was the company we hired.”

“It wasn’t me” gets us nowhere.

DMA is in charge of North Carolina Medicaid.  Yet every time DMA is questioned about Medicaid issues,, “It wasn’t THEM.” Who was it?

If “someone” makes a decision at DMA, that “someone” should attend the reconsideration review to defend that “someone’s” action. “It’s not me” means “I understand that you’ve been accused of wrongdoing; I understand that your company is financially in stress because of “someone’s” determination that you have committed wrongdoing, I understand that your Medicaid recipients may not have a health care provider because of “someone’s”determination, but DMA decided that that “someone” does not need to be accountable. Instead DMA will send “another someone” with zero information, hat way, the “someone” to blame is NOT DMA.”

It wasn’t me.


About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on March 18, 2013, in Division of Medical Assistance, Health Care Providers and Services, MCO, Medicaid, Medicaid Appeals, Medicaid Audits, Medicaid Recoupment, Mental Health, NC DHHS, NC DMA Clinical Coverage Policy 8C, North Carolina, Outpatient Behavioral Health, Reconsideration Reviews, Tentative Notices of Overpayment and tagged , , , , , , . Bookmark the permalink. 5 Comments.

  1. When are these people going to be held accountable for these horrible audits? Why isn’t anyone in the NC General Assembly doing anything about DMA and their hired commissioned based Audit firms?

    • My honest answer is I have no idea. These audits are creating so many problems. Providers are going out of business. Medicaid recipients are suffering. And all because the auditing companies have no supervision. It’s ludicrous. But I’m not sure how much the General Assembly understands.

  2. The General Assembly probably understands next to nothing. They have authorized hiring entities to oversee and manage the process. They are most likely receiving the “mushroom treatment”. Hearings before the responsible committees would likely be very enlightening, though every effort would likely be made to avoid such hearings.

  3. Ed….ever been to an LOC (Legislative Oversight Committee) meeting? You will hear a lot of “….I can get you that information….” responses from DHHS and DMA employees when they are asked specific questions by committee members. I wonder if A) the information is actually forwarded to the legislatures requesting it and B) if anything is actually done with the information once it is received.

    • I have seen that process, which generally involves sending the wrong person to the hearing or sending the right person without proper support. A list of specific questions submitted to the agency beforehand can help, particularly if supplied to the oversight committee by knowledgeable, motivated attorneys who represent the “harassed”. An invitation to return before the committee the following day with the requested information can also be “inspirational” (as in the Richard Prior quote regarding fire). 😉

      I spent my career in a regulated industry. When a state utility commission or a state consumers’ counsel requested information, it was provided.

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