Fear Prevents Medicaid Providers From Fighting DMA: Fear of Retaliation?

A client called me today asking whether there was anything he could do legally against the Division of Medical Assistance (DMA) for terminating his Medicaid contract. The convo went something like this:

“Of course,” I said. “When was your Medicaid contract terminated?”
“Last January.”
“As in, January 2012?”
“Why didn’t you call me January 2012?
“Because I was scared of retaliation by DMA.”

What I did NOT say: You were scared of retaliation by DMA when you were wrongly terminated from your Medicaid contract, your company was forced to file bankruptcy and dissolve, you, personally, lost your livelihood, your company, and your self-worth, you were forced to terminate all staff, and all Medicaid recipients were forced to be discharged???? What else could possibly happen? Maybe DMA could’ve kicked your dog.

In all seriousness, most of the time, this fear of retaliation comes way before all the dire and irreparable consequences. Such as a provider refuses to seek legal counsel when the provider is initially placed on prepayment review. Normally the provider thinks, “I can get through this,” “70% is not that hard,” “My documents are compliant,” or “If I get counsel, DMA will just retaliate.”

Most health care providers view their roles in society as helping people. The thought of hiring an attorney is against the providers’ very core being, like rubbing a shark against its grain.

Yet, the fact is that the government is not always right. The government’s contracted companies are not always right. Or even better, the way the employees hired by the contracted companies complete their tasks is similar to playing “phone” in grade school. The employees hired by the contracted companies get their work orders from supervisors hired by contracted companies, who, in turn, get their work orders from someone else hired by the contracted companies, and so on. The hierarchy of order creates a distorted work order.

For example, perhaps the DMA employee who hired the contracted company stated, “Always follow DMA Clinical Policies and federal and state law. When in doubt err on the side of the provider.”

But 20 people down the line, you have Ms. Sweet (fictional) from the Carolinas Center of Medical Excellence (CCME) getting paid $10/hour going to providers’ offices with her standing orders as she understands them as “Always follow DMA policies. When in doubt err on the side of the State.” It’s not Ms. Sweet’s fault that the audit is conducted incorrectly, but, regardless of fault, the audit is conducted incorrectly.

The provider, during the whole process, believes Ms. Sweet when Ms. Sweet states that she knows what she is doing, has hope vested in all the telephone calls made to Program Integrity (PI) in which PI informed the provider that its documents are “great” or “some of the best they’ve seen,” only to open the mailbox a week later with a letter stating the provider’s Medicaid contract had been terminated with a signature from the very person from PI that informed the provider that the documents were “great.” (And of course, the provider took no notes of any telephone calls….But Attorney X, I swear John Doe at PI told me my documents were great!)

I have a saying (that I just made up) In Medicaid, your fear of the unknown coupled with your nonaction will cause all those fears to come true.

In the words of Arthur Ashe: “Fear isn’t an excuse to come to a standstill. It’s the impetus to step up and strike.”

Standing still in the face of Medicaid unknown allows DMA (or whatever contracted company) to decide your fate without hearing your side. If you think DMA or PI (or whatever entity) is listening to your side, then, at the very least, take copious notes of all conversations, write memos to the file regarding conversations, and prepare for the worst.

In my experience fear of DMA does nothing except create negative consequences.

So instead of blissfully following PCG or CCME or HP Enterprises (the Recovery Audit Companies)’s audit requirements and receiving denial after denial (despite your knowledge that the documents were in compliance), don’t wait until your Medciaid contract is terminated. Be proactive. Shake off your fear of retaliation by DMA. Buck up. The only thing to fear, is fear itself. Put on your big boy pants. Stand strong. Don’t get run over. Put on your dancing shoes. Get a stiff upper lip.

(Ok, I’m out of cliches)

About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on April 15, 2013, in CCME, Division of Medical Assistance, Fraud, Harassment, Health Care Providers and Services, MCO, Medicaid, Medicaid Audits, Medicaid Contracts, NC DHHS, North Carolina, Prepayment Review, Program Integrity, Provider Medicaid Contracts, Termination of Medicaid Contract and tagged , , , , , , , , . Bookmark the permalink. 5 Comments.

  1. Hi Knicole, I am one of those providers who has lived in that fear. I have a payback to the state for 303000.00 that I can no longer pay due to paybacks to the local MCO. That may sound like I am a careless provider who cannot get it right. I am not.With the first payback I had to cut office staff and QP staff down to a very few people to make a 20,000/ month payment. When Innovations and the MCO came in 2012, clerical errors and poor guidance from the MCO are forcing me to close my business.
    The state payback came from the fact the LME had not reviewed my company for the Home Supports service within the 6 weeks of providing the service. The LME knew I was providing it. I did call for them to come and review my chart. The home Support service is the same Residential supports but a family member does the service.
    I was devastated. I did the appeal myself by letter detailing the information. I lost the appeal.
    So I have paid over 200,000. I have stopped making these payments to pay my MCO.
    I am closing my doors on 4/30 after 10 years of business.
    I am closing for clerical errors. I have provided the Medicaid services. ALL my IDD clients received their services. I treated all of my contractors and office staff well.

    I am very angry with the system. Providers are in fear. The former relationship we have had with the LME which was friendly and we worked together to solve issues. It no longer exists.

    I understand the place where your client comes from in his statements.

    • First, I am so sorry that you had been forced to close your business of 10 years for clerical errors. I wish I could say you are an anomaly, but you aren’t. Sadly this is happening to so many providers. The fear is real. Providers such as yourself don’t get legal representation because getting a lawyer (to a provider) is seen as loading a gun. The providers are afraid that the state will do worse if the gun is loaded. But, Tracy, I hope you tell other providers in this situation to load up. The state sure loads up.

  2. I will tell providers. I also tell every provider that I speak with that has concerns about this MCO system and its bullying tactics to go to your blog and get educated. I do not mean just reading what you write(It is great stuff!) but also follow your links.
    You really stand up for the providers and I personall so appreciate it. Most small providers do not know where to turn to educated from someone that is not part of the system. You are the light in the tunnel and I thank you for your help and your fierceness.

  3. A motіvating discussion is worth cοmment. There’s no
    doubt that that you ought to ρublish more about this issue, іt might not
    be a taboo matter but typicallу folks don’t disсuss such issues.
    To the next! All the best!!

Leave a Reply

%d bloggers like this: