Monthly Archives: May 2013

“If Freud Accepted Medicaid…” (Thoughts From an ACSW, LCSW)

Mr. Geoffrey Zeger, ACSW, LCSW wrote the following humorous, yet true segment:

I haven’t written to the ‘NC Mental Hope’ listserv for a while but recently I’ve been thinking…. 

If Freud accepted NC Medicaid and he cured ‘The Wofman’ but did not draft a Treatment Plan in the proper format he would have had to pay back all the money for the treatment sessions (Click here for info. on ‘The Wolfman’ —>

 If Dr. Emil Kraepelin accepted NC Medicaid and not only classified and described Schizophrenia for the first time but was on the verge of curing it, but he did not submit a Service Order for more authorized sessions, he would have had to stop providing treatment (Click here for info on Dr. Kraepelin —>

 If Dr. Marsha Linehan  accepted NC Medicaid and not only developed DBT but helped a client stop cutting on themselves on a daily basis and move to a place of emotional regulation and stability, but she did not write the start time of her sessions on her progress notes she would have been put on a pre-payment review and all of her payments delayed (Click here for info. on DBT —>

 …I am glad that the Giants on whose shoulders we stand on did not accept NC Medicaid.

 I recall a lesson from a long time ago in my Policy and Administration class in the School of Social Work (funny how some things stick, huh?).  The Professor discussed how a frequent trap in the administration of social services is the erosion of goals through the focus on process.  The goal and process become confused.  Looking at the macro, this is happening with NC Medicaid.  The process (documentation, authorizations, Alpha and Provider Connect, LOCUS/CALOCUS, etc., etc.) should be in support of the goal (client care) and not be a hindrance to it.  Unfortunately, what is happening is the process has BECOME the goal – providers are more focused on crossing t’s and dotting i’s, jumping through hoops, making sure that documentation is ‘audit proof,’ and hoping that auditors will be merciful than on providing the best clinical service available.  This deflection of effort diminishes client care.

 Now, trying to think like a NC Legislator or a DMA employee, perhaps the theory is that if the lane is restricted enough and there are enough regulations and dis-incentives (payment consequences) put in place then the providers will be structured to the point of providing appropriate care.  Well, we all know how this is working out (

 In my private practice I found that these regulations caused the ’80-20 Rule’ ( – 20 percent of my case load were NC Medicaid clients and the regulations were taking 80 percent of my time.  The paperwork, service orders, authorizations, use of the LME/MCO computer based system, implementation reviews, audits, financial pay-backs for paper work technicalities and plans of correction became time, resource and cost prohibitive.    

 I have done my best to persevere through the user unfriendly labyrinth but recently stopped accepting NC Medicaid clients at my private practice.  This occurred with mixed feelings — less stress and an ability to re focus on client care for my other clients but a sense of guilt. Realistically, I know that for the sake of my business and family this had to be done but there is that little voice in my head saying “…good social workers help the impoverished and socioeconomically challenged.”  I still contract at agencies that accept Medicaid and IPRS and keep my fingers crossed that we will be able to weather the pressure.  

 What is sad is when I get a call from a potential client with NC Medicaid at my private practice and I tell them I am no longer accepting Medicaid – they invariably say “…I can’t find anyone who takes Medicaid!!! The therapist I used to see stopped taking it and now I don’t know what to do!!! I’ve been calling all over…”  I have to refer them to the intake line at the LME/MCO and hope they are referred to an agency that will not shut down in 3 months.    

 I wonder how many providers will be left standing as this continues.  I also wonder how some colleagues of mine will fair in the future – those clinicians who lost jobs as their agencies closed and went to what they thought was the safe haven of a job with the LME/MCO’s….will they still have jobs in 2 years when McCrory’s Medicaid Reform condenses mental health and physical health and reduces 10 LME/MCO’s to 3 CCE’s.  

 The saga continues…

 Geoffrey Zeger, ACSW, LCSW

Adult Medicaid Group Homes: Forgotten Again?

In the wake of such tragedies such as the Colorado movie theatre last July, the Sikh temple in Wisconsin in August, Minneapolis in September, then the unthinkable massacre at the Connecticut elementary school in December, and, of course, the Boston bombing in April, you would think that mental health would be a top priority.

Instead, politicians across America are advocating gun laws.  Without commenting on gun control (as this is a Medicaid blog), mental health seems to be getting placed on the back-burner.

In the North Carolina budget passed by the Senate last week, mental health, in particular, group homes for adults with severe mental illnesses, again, was forgotten.  Whether on purpose or by accident, I have no idea.  But the fact remains a large part of metal health simply was not contemplated in the budget.

I am sure most of you remember the comedy of errors that occurred at the beginning of the year when the criteria for personal care services (PCS) was revised.  Basically in January 2013, the criteria to receive PCS became more stringent.

According to DMA, effective January 1, 2013, PCS “is available to individuals who has a medical condition, disability, or cognitive impairment and demonstrates unmet needs for, at a minimum three of the five qualifying activities of daily living (ADLs) with limited hands-on assistance; two ADLs, one of which requires extensive assistance; or two ADLs, one of which requires assistance at the full dependence level. The five qualifying ADLs are eating, dressing, bathing, toileting, and mobility.”

Prior to January 1, 2013, individuals who qualified for Medicaid special room and board assistance were automatically granted approval to receive PCS funding regardless of need. This applied for both in-home and facility-based services.

Due to the more stringent 2013 criteria, thousands of adults in group homes in NC who depended on Medicaid were no longer eligible.  Former Gov. Perdue was forced to shimmy around funds in order to keep these disabled adults from losing their homes.  The whole debacle created terror and stress for those disabled adults whose residences were threatened, for the families of the threatened disabled adults, for the group home executives who did not want to evict these disabled adults, and for any mental health advocate or person with empathy toward the mentally ill.

The trainwreck of the adult PCS group homes only occurred 4-ish months ago.

Yet, lawmakers, seemingly, failed to address the recurrent problem of funding for group homes for adults with severe mental illnesses, who are no longer eligible for PCS, in last week’s budget passed by Senate.

Wednesday afternoon (if you work downtown, then you know what I am talking about) a group of protesters rallied outside the General Assembly clad in blue shirts, holding signs saying, “Save Group Homes!” and “Disaster Relief! Save my Home!,” and some simply said, “Help!”

The Senate’s budget failed to provide funds for approximately 1,450 people living in 6-person group homes.  Each group home resident currently receives $16.14 a day, or about $6,000 a year, from the state program.  The fear is that group homes are so underfunded as it is that any amount, no matter how small, of decreased funds would drive the group homes out of business, forcing residents onto the street.

In general, group homes are not huge money-makers for the owners.  The workers at a group home make approximately $9-10/hour.  Group homes must be staffed 24/hours/day and 365/days/year.  The group homes must use the state-funded money to staff the home, keep up the maintenance of the home, feed all the residents and care for all the residents, plus all overhead (i.e., electricity, heat/air conditioning, any extras for the residents, such as TVs or cable, blankets, etc.).  Plus group homes must provide a small, monthly stipend for the residents in order for the residents purchase medicine (co-pays) and personal hygiene products.

Logically there must be SOME profit in group homes in order for anyone to want to run a group home.  But the profit is minimal.

Similar to the low Medicaid reimbursement rates to physicians, causing physicians to not accept Medicaid, any sort of cut to group home funding (including the residents not qualifying for PCS due to the new criteria and without special funding to cover the difference), group homes will inevitably close.  You simply cannot expect a person to keep a group home open when no profit is made.  Just as if you cannot expect a doctor to accept Medicaid patients if no profit is made.

So, is the State of North Carolina saving money by not providing additional funding to those PCS recipients who no longer qualify for PCS? Hey, the Medicaid budget goes down, right? But what happens to those adults with severe mental illnesses when, because of the lack of PCS funds, the group homes either close or turn out those residents who no longer qualify for PCS?

In a perfect world, I guess the families of the adult Medicaid recipients would take them in and all would be fine.  But I gather there is a reason that these recipients are in a group home and not with family.

No, since this is not a perfect world, most of these adults with severe mental illnesses, without a group home, would be homeless and, eventually, if not immediately, would be hospitalized at a much higher price that a group home.

So these adult Medicaid recipients are stable in a group home. Well-cared for. Most likely, have relationships with the staff and other residents.  But because of the new PCS criteria and the fact that the NC budget does not provide funding for Medicaid residents that no longer qualify for the PCS funding, we will uproot the adults with severe mental illness, send them into the world, expect them to be ok, and, then, later, pay much more money to the hospitals that are forced to take in these Medicaid recipients due to whatever issues caused the hospitalization.

Hmmmm….at least the Medicaid budget is lower.

DMA, LIke the Titanic, Has Difficulty Changing Course

At a preliminary injunction hearing today, I realized that NC Division of Medical Assistance (DMA), like the Titanic, has difficulty changing its course.

It is my contention (and, I argue, the 4th Circuit’s position, as well) that a Managed Care Organization (MCO) does not have the authority, without DMA’s express authorization, to terminate, suspend or refuse to contract with any provider.  PERIOD.  I don’t care if the provider has phantom clients and is billing Medicaid 34/hr/day.  (People, I am obviously against Medicaid fraud. I am trying to make a point).

An MCO cannot, without express authorization from DMA, terminate, suspend, or refuse to contract with any provider.

Why do I think this? (besides the fact that this is a better position for my clients). And why do I think DMA is Titanic-like?

On or about May 10, 2013, the 4th Circuit published K.C. v. Shipman (“Shipman”).  The second sentence of Shipman says it all, “PBH [the MCO at-issue in this particular case], a local subdivision of the state that  manages the delivery of plaintiffs’ Medicaid services pursuant to a contract with NCDHHS.” Hmmmm…too legalese-like?

FYI: NCDHHS = NC Dept. of Health and Human Services (DHHS), which is the state agency that manages DMA, which is the division that manages Medicaid.  For a complete list of DHHS’ divisions, click here.

Shipman goes on to say, “states should enjoy both an administrative benefit (the ability to designate a single state agency to make final decisions  in the interest of efficiency) but also a corresponding burden (an accountability regime in which an agency cannot evade federal requirements by deferring to the actions of other entities).” (emphasis added).  Accountability, People!!!  That’s what I am talking about!

In other words, DMA, as the single state entity, cannot contract with a third-party and NOT carry the burden of supervising that third-party and insuring that the third-party follows federal law. Or even simpler, the single state entity cannot contract out of (or divorce itself from) federal laws and hide behind a contract.  Or even simpler, a teacher at a school cannot suspend a student without the authorization of the principal/school.

Yet, despite Shipman, MCOs are still contending that, “DMA cannot tell us what to do.”

Yet, despite Shipman, MCOs are still terminating, suspending and refusing to contract with providers without the express authority of DMA.

Yet, despite Shipman, TODAY, in my preliminary injunction hearing (the transcript of which will be a public record), the MCO’s attorney argued that (per case law from 1941) the MCO is an independent contractor (hence DMA having no control over the MCO).  The DMA attorney piggy-backed the MCO argument and pointed out that DMA had taken no action in this case (i.e., the provider’s Medicaid contract was NOT terminated according to DMA).  In other words, the teacher tried to expel a student from school without the school/principal authorizing the expulsion…or even backing it up.

It is as if Shipman came out May 10, 2013, and, here on now May 28, DMA (or its agents the MCOs) is struggling to change its course.  But, like the Titanic, DMA is too big, too heavy and too dinosaur-ish to move quickly adapt or change to comply with new federal law (although, even prior to Shipman, I argued it is absolutely obvious that an MCO is the agent of the state…it’s just nice to have some “auth-or-i-TIE” to back my argument).

“Iceberg!” (Shipman)

At the moment that someone yelled, “Iceberg,” what did the Titanic do?

1. Some say the officer in charge had a 30 second delay in giving the order to change the ship’s course after the spotting of the iceberg.  Apparently, he was dumbfounded for 30 seconds.  Can’t say I blame him.  Pretty scary stuff!  But, some say, that 30 second delay sunk the Titanic.

2. Some say when the iceberg was spotted, the steersman, Robert Hitchins, went into a panic and turned the Titanic the wrong way.  Remember, the Titanic was launched back when sailors were more used to sailing ships.  They learned on “Tiller Orders.”  If you want to go one way, you push the tiller the other way.  So it is not surprising that, in a panic, Hitchins would have resorted to Tillers Orders.

3. Some say the Titanic sank because it was the largest ship afloat.  The Titanic was only the second of three Olympic class ocean liners operated by White Star Line.  It carried 2,224 passengers.  Because of the Titanic’s massive size, the hull plates buckled inward along her starboard side and opened 5 of 16 watertight compartments to the sea.

4. Some say (this has nothing to do with sinking, but with loss of life), the Titanic lacked enough lifeboats.  The Titanic had enough lifeboats for 1,178 people, slightly more than 1/2 of the passengers.  Supposedly, the reason the Titanic had insufficient lifeboats was because of outdated maritime safety regulations.

Similarly, DMA, like the Titanic, has made some “sink-able” errors, but with administration committed to change, let’s hope we can correct the “sink-able” errors before the Medicaid behavioral health system sinks.  Because, instead of 2,224 passengers, Medicaid carries 1.5 million passengers.

Let’s review  the Titanic-like errors of DMA. For the sake of this blog, the “Iceberg!” moment was the publication of K.C. v. Shipman.

1. K.C. v. Shipman was published May 10, 2013.  It is now May 28, and DMA and the MCOs are still arguing in court that MCOs are not agents of DMA.  An 18 day delay is a bit more than a 30 second delay, but the similarity is there nonetheless.

2. A panicked turn the wrong way…Shipman came out and legal advocates for DMA and the MCOs instantly begin to argue, “Yeah, but…”  Yeah, but Shipman does not apply to providers…Yeah, but Shipman only applies to managed care, not fee-for-services…Yeah, but just because PBH is an agent of the state, it does not mean that all MCOS are agents. Folks, an agent is an agent is an agent.  A panicked turn the wrong way is merely a way of denial (and I am not talking about the river De-Nile).  And, some say, the panicked turn the wrong way sunk the Titanic.

3.  Largest ship afloat; large bureaucratic agency.  I do not have the data, but I am willing to bet that DHHS/DMA is one of the biggest NC governmental agencies.  In January, the State Auditor released a Medicaid audit.  According to the January audit, “[i]n SFY 2011, North Carolina Medicaid incurred administrative expenses of approximately $648.8 million which when compared to MAP spending of $10.3 billion produced an ADM/MAP percentage of 6.3 percent. This percentage was significantly greater than the ratio for states with comparable spending.”  With that much spending on administration, the agency can’t be small!  Like the Titanic, big things are hard to maneuver or change course.  The hull plates begin to buckle. Imagine an elephant going through an obstacle course at top speed…it just isn’t pretty.

4.   Like too few lifeboats, Medicaid’s mental health system has too few providers and too many wanting for a seat on the lifeboat.  Not to mention, the MCOs seem to have taken it upon themselves to insure there are too few providers by terminating Medicaid contracts, suspending Medicaid contracts and refusing to enroll providers.  Today, my client informed me (and, folks, this is not verified; it is hearsay) that during the time in which this provider’s certain Medicaid contracts were terminated by this one MCO, that this one MCO also terminated 27 other providers’ Medicaid contracts.  It’s as if, prior to setting sail, a person brought the captain an extra few thousand lifeboats, and, instead of putting the lifeboats on the ship, the captain said, “No thanks. We don’t have room.”  But as to Medicaid behavioral health, we have too many in need and not enough providers providing services.  (Again, this does not go to the reason of the sink-age  (I know that is not a word) of the Titanic, but rather to the number of deaths/recipients not receiving medically necessary mental health services.

In sum, today I decided that DMA is like the Titanic.  So big that both were/are very difficult to change its course.  Since Shipman, DMA has had an 18 day delay digesting the decision (and counting).  Since Shipman, DMA has panicked and turned the wrong way.  Since Shipman, DMA has shown it is just too big to move quickly (and it’s hulls may be buckling).  Since Shipman, DMA has proven too little providers and too many Medicaid recipients in-need is not a healthy combination.

Remember the saying, “[T]hose that do not learn from history are doomed to repeat it?”

People, the Titanic sank!

Secretary Aldona Wos: Inherited a Medicaid Money Pit? (It’s Not All Her Fault)

Have you ever bought a used car only to find out it is a lemon? Or a house only to find it is a money pit? Well, I suspect that sinking feeling is much like how Secretary Aldona Wos feels after inheriting the NC Medicaid system.

There is no question that Secretary Wos inherited a lemon…or, even more apropos,…a Medicaid money pit.

Remember, in the January 2013 Medicaid Audit conducted by State Auditor Beth Wood, the audit found Medicaid to be a total of almost $1.2 billion over budget during the past three fiscal years.  (FYI: The Fiscal Year begins July 1 and ends June 30.  Hence, the need for a new budget now that this Fiscal Year is fast-ending.) The January Audit concluded that (not this year) but the last 3 years, Medicaid was over budget by a total of almost $1.2 billion.  The past 3 Fiscal Years were, obviously, before Secretary Wos’ stent as NC Director of the Department of Health and Human Services (DHHS).

Secretary Wos did not only inherit a “money pit” Medicaid system as it pertains to the budget.  Think about how expensive NCTracks is turning out to be.  But NCTracks was not Secretary Wos’ “baby.”  The past administration implemented the new NCTracks system, which is still not “live.”  Originally NCTracks was set to go live August 2011 at a cost of $265 million.  When the contract was put out for bid in 2008 (for the second time), Computer Sciences Company (CSC) hired former legislator and DHHS Deputy Secretary Lanier Cansler as its lobbyist. Shortly after CSC landed the contract, Perdue named Cansler as her DHHS secretary. (Hmmmm).

NCTracks now brags the hefty price tag of $484 million and is scheduled to go live July 1, 2013. The project is now the most expensive contract in state history.

A new audit released Wednesday says DHHS failed to fully test NCTracks.  According to the N&O, “[o]f 834 “Critical Priority Test Cases” set to be performed on the new system, it failed 123. The audit says 285 of the “critical” tests, more than one quarter, were never performed.”

Now many people are criticizing Secretary Wos for the price tag of NCTracks. But prior to pointing fingers, remember from where NCTracks came. And the $1.2 over budget for the last 3 years.

Now this blog is NOT a “let’s all get to together and applaud the new Secretary; we all think she is the bee’s knees; all our Medicaid questions have been answered.”

I am merely pointing out that inheriting a money pit must be a burden.  After only five months or so on the job, Secretary Wos has received much criticism; yet many critiques are aimed at “inherited bads.”

Believe me, the current MCO situation (which, although new and may or may not have been Sect. Wos’ doing…although I tend to think not since PBH has been our pilot for years prior) is as catastrophic for the behavioral health providers as a warm day is to Frosty the Snowman.

But at a recent, town-hall-style meeting in Durham, I asked my tugging question.  My tugging question for so long has been, “How is the Department of Health and Human Services (DHHS), Division of Medical Assistance (DMA) supervising the Managed Care Organizations (MCOs)?” Well, I asked the question. (Important legal disclaimer…I did NOT ask this question as an attorney. I asked this question as a quasi-journalist for this blog at a public forum. I was NOT representing any party, only my mere legal curiosity).

Sect. Wos’ answer? “Call me.” (These quotes may not be exact…but very close).

“If you have specific questions for specific providers, call me and I will see what I can do.”

Wow! Really? Someone who will actually listen?  Well, I got the phone number of her assistant.  A Ricky Diaz.

The next day I realized sadly that IF I DID contact Sect. Wos for a specific provider, that as an attorney, if I spoke to Sect. Wos about a specific provider, that I could be accused of ex parte communications with a represented party. And they would be right.  So I was stuck between a rock and a hard place.  (We’d all be fine if not for these dag on laws…)

So, here we are, a real possibility that going straight to the top could help my clients, but this legal, ethical dilemma overpowers.  So I contacted the AG’s office and asked for a telephone conference with Emery Milliken, the general counsel of DHHS, any AG that would like to be involved, Sect. Wos and me.  I also contacted Ricky Diaz and asked to schedule a telephone conference with Sect. Wos, me, and whatever counsel Sect. Wos wants.

That was over a week ago.

The lack of supervision over the MCOs has put many good providers out of business, has neglected to provide many Medicaid recipients of their medically necessary needs, has forced so many good providers to fire staff and not provide Medicaid services (due to the MCOs denying services of Medicaid recipients and refusing/terminating Medicaid contracts with good behavioral health care providers).

Call me naive, but I actually think if I spoke to Sect. Wos, she would care and try her best to remedy the catastrophic situation for behavioral health providers.  Maybe not. But one can dream.

June 1st: Medicaid Behavioral Health Provider Meeting!! Recovering Monetary Damages!!!

This is a solicitation. (This is an effort to thwart any possible assertions that my disclaimer is not enough. I have put my warning.  See also my disclaimer). 

In fact, this is a group of providers meeting together who have been wronged monetarily by the Medicaid system, whether by DMA, the MCOs, and/or the RACs, to discuss future options.  We had a similar group session May 11, 2012, in Raleigh and it was met with great success! Many providers attended.  We were able to share stories.  At the end of the meeting, everyone was excited for the future. So we wanted to host one more meeting in the western portion of the state to invite additional providers.  June 15th will be our cut-off.  If you are interested in this cause, please come to our June 1st meeting!!!

WHEN: 06.01.2013

WHERE: The Cornwell Center at Myers Park Baptist Church, 2001 Selwyn Avenue, Charlotte, NC

WHO: (Any provider that answers “Yes” to the following questions)

  • Have you been placed on Pre-Payment Status and been unable to meet the standards to get off of Pre-payment Status?
  • Have you been told that you are not in good standing with DMA and have been unable to receive assistance restoring your standing?
  • Have you been wrongly denied access to one of the new MCO provider networks?
  • Have you been told that your Medicaid number is being terminated or has been terminated?
  • Have your Medicaid payments been wrongly suspended?
  • Have these actions resulted in loss of income, your business closing, emotional stress, or other negative consequences?
  • Have you received a Tentative Notice of Overpayment stating that you must pay back money to the State?

If so, please join us!


Knicole C. Emanuel

Lunch will be provided so please RSVP to by clicking the REGISTER NOW link.

Questions? Please contact Caitlin Williamson at or 804.420.6267.

Knicole C. Emanuel – 919.981.4031 –

Medicaid Dental Post-Payment Audits Gone Awry: A Hypothetical Example

A dental practice was audited by Public Consultant Group (PCG). Here is their story: (Insert a Dum, Dum, Dum).

For those of you who do not know who PCG is: CONGRATULATIONS!

But there are those of us who know that PCG is a hired contractor by the state or the Division of Medical Assistance (DMA) to investigate providers who accept Medicaid in North Carolina to detect clinically suspect behaviors or administrative billing patterns, which could indicate potentially abusive or fraudulent activities.

Whew!! Sounds serious!!

I am SURE that, for such a serious mission, PCG employs only the most-highly competent employees who are super, duper knowledgeable about the esoteric idiosyncrasies of the Medicaid system, the appropriate policy(ies),and  federal and state rules and regulations, right?

Hmmmm…out of sheer curiosity I googled employment opportunities at PCG.  I found a position in Albany, NY for an “Instructional Trainer.”  Duties include:

“Coaches agencies and providers on programs and information to ensure compliance with departmental, state, and federal laws, rules, regulations, guidelines, processes, and procedures.”

Dag on!!! Shut the front door! This person will be coaching agencies and providers, ensuring compliance with laws, rules, regulations, guidelines….SURELY this person must be a lawyer, right????

So then I looked at the “required experience:”

Required Experience:

  • BS degree in a related field preferred
  • Experience in development and delivery of instructional materials or training
  • Experience in health & human services is desirable
  • Experience working in a team-oriented, collaborative environment
  • Advanced Knowledge of Curriculum Design and Training Delivery
  • Advanced Knowledge of Office Skills such as Word Processing and Data Collection
  • Advanced Knowledge of the Principles for Providing Customer Service

A BS degree is a related field preferred??

First, what is a related field for regulations and compliance? Political Science?

Folks, I double-majored in English and Political Science and I can promise you that after graduating from NCSU with a double major in English and “Poli Sci” I was NOWHERE competent enough to handle a Medicaid audit of a provider.  I may have been able to draft a darn good essay or quote the U.S. Senators and their bipartisan affiliations, but a Medicaid expert, I was not.  And this position was for an “Instructional Trainer!” A TRAINER!! As in, one who trains.  Implicit in the job title is “One who has been trained” or “One who has the knowledge to train.”

I give this background to set the stage:

The Characters:

On one side: Dentists who have been managing a successful dental practice for years and years after attending college and dental school.

And on the other side:  A college Political Science major who is able to recite all the states and its capitols and all the governors of each state (This is not to say that all employees at PCG are inept…or not qualified for  their particular position.  I actually know a couple of PCG employees of whom I think highly (this is not directed toward you, my fine two friends).  This is merely a generalization and stage-setting for the all-too-common errors I see committed by the “entry-level” auditors).

The stage:

A well-established dental practice.  All the walls are wooden (painted white) and there are 200+ handprints on the lobby wall with all the little pediatric customers’ names on them.  There is a waiting room with toys and books.

The script:

Act 1: A few entry-level PCG auditors knock on the door of the dental practice (They don’t actually knock, because it is a dental practice, not a home, but you get the drift).

Receptionist: How may we help you?

Auditor 1: We are here to conduct a Medicaid post-payment audit.

Receptionist: Huh? (With an open, gape-jawed expression)

Auditor 2: A post-payment Medicaid audit.

Auditor 1: We need to see all the documents of your Medicaid clients from February 2011 through May 2011.

Receptionist: Huh?

All right, folks, I am sure you get the point.  So the audit occurs and a few months later, the dental practice receives a Tentative Notice of Overpayment for $300,000.00.  The #1 main reason PCG found noncompliance was:

“The attending provider number billed does not match the individual dentist who rendered the service and does not support service billed.  Citation: Clinical Coverage Policy No. 4A: January 1, 2011 Attachment A.1 Instructions for filing a Dental Claim 53-56…”

Now, mind you, in the DMA Clinical Policy No. 4A, revised March 1, 2013, the policy states “Enter the attending provider’s NPI for the individual dentist rendering service. (This number must correspond to the signature in field 53.)”

In 2013, it is quite clear that the attending provider and the provider rendering the services must be identical.  But this audit was a post-payment review, meaning that the documents audited were from 2011, not 2013.

In 2011, the DMA Clinical Policy No. 4A, revised January 1, 2011, states “Enter the attending provider’s NPI for the individual dentist rendering service. (This number should correspond to the signature in field 53.)”

 See the difference? (One of these things is not  like the others).

Must v. Should

Must equals no other choice.  Should denotes guidance; simply a suggestion.

However, think of this, if you were a college graduate who majored in Political Science and were now auditing Medicaid providers, would you think to distinguish the difference between “should” and “must?”


Possible Alternative Methods to Decrease Medicaid Spending (Other Than Providing Less Services to Less Recipients)

The Triangle Business Journal published an interesting article today that sets forth a plan to decrease Medicaid billing without decreasing the services provided to Medicaid less Medicaid recipients.  See below:

This article was sent to you by

Report: How to squeeze $74B from Medicaid

Published: May 20, 2013

Two new health care reports could offer N.C. Gov. Pat McCrory some insight during efforts to reform the state’s “broken” $13 billion Medicaid budget.

View full article

Large Number of NC Mental Health Providers No Longer Accepting Medicaid

Since the onslaught of the Medicaid audits on NC health care providers who accept Medicaid, I have been curious as to how many providers have determined that they no longer wanted to accept Medicaid.  Most of my clients have mentioned the fact that after their current issue (whatever that issue is), they were not going to deal with Medicaid anymore.  They are sick of the erroneous audits, the difficulty in dealing with the MCOs, the pile of paperwork they have to provide to state agencies over and over due to post or prepayment review. They are done with Medicaid.

Why should we care whether these providers continue to accept Medicaid?

Let’s not lose sight of the Medicaid recipients.  All these MCOs, RACs and other state agencies are so hell-bent on saving/recouping money, that Medicaid recipients’ mental health care has been lost.  1.5 million North Carolinians rely on Medicaid for their insurance.  Yet, less than 60% of physicians/providers accept Medicaid.  Even less accept Medicaid when you get into specialized services (approximately 30% dentists in NC accept Medicaid).  We need the providers who are willing to accept Medicaid.  Medicaid recipients need providers who are willing to accept Medicaid.

This is not the first time providers have been squeezed out of the Medicaid system.  Remember back in January 2011, approximately 1800 mental health providers were squeezed out of the system with the implementation of CABHA.  All the Medicaid recipients that were seen by providers who were squeezed out, were forced to transfer to other providers.  Again, no apparent thought to the care of the Medicaid recipients.

Now, in 2012 and 2013 and beyond, more mental health care providers are being squeezed out due to Medicaid audits, prepayment reviews, post-payment reviews, and suspensions of Medicaid reimbursements (all of which are grossly incorrectly administered).

So what happens to the 1.5 million Medicaid recipients?  Somehow the Medicaid recipients’ needs are being lost.  MCOs are terminating good provider contracts; RACs are auditing good providers out of business.  The Medicaid recipients are not receiving services.

Until now, I have seen no data on the number of providers that have recently decided to no longer accept Medicaid.

Mecklenburg Psychological Association (MPA) has calculated the decrease in mental health providers in Mecklenburg County by analyzing changes in members insurance participation from 2011/2012 to 2013 ( 2011 & 2012 are combined).

The data do not indicate a reason as to why providers dropped their Medicaid participation.  And remember, this data only apply to Mecklenburg County.  But here is the data:

Insurance Participation Changes of MPA members from 2011/2012 to 2013
  2011 & 2012
Number of Members
None (take no insurance)
BC/BS State
NC HealthChoice
United Behavioral Health
Value Options
Medicaid Changes
No longer accept Medicaid
Moved – did not renew MPA Membership
Did not renew MPA Membership in 2013
New – members who accept Medicaid
MPA 3013 Non-renewers
No response
New Members 2013

Wow. In one county in NC, from 2011/2012 to 2013, 31 providers have opted to no longer accept Medicaid.

Makes you wonder where the Medicaid recipients are now that their providers no longer accept Medicaid.  I guess the Medicaid recipients’ needs are still lost.

CMS Adding 5th RAC: Medicaid Audits Expected to Increase

It is wise to worry about tomorrow today.  -Aesop’s Fables, “The Ant and the Grasshopper”

CMS has announced that it will add a 5th Medicare RAC to focus on home health and durable medical equipment (DME).  Obviously, with the aid of a 5th RAC, the other RACs will have more free time to focus on other health care providers.

So what does a 5th RAC for Medicare mean for Medicaid in North Carolina.  First, many providers that accept Medicare also accept Medicaid.  The two programs do have some commonality.  Also, NC started out with one RAC.  As the federal government increased the number of RACs, NC has slowly increased the number of RACs.  We started with Public Consulting Group (PCG) in January 2012 and added HMS October 2012.  Then, of course, we have The Carolina Centers for Medical Excellence (CCME), approved through an RFP, performing “Quality Improvement Strategy functions” on the behalf of DMA.

Expected Future for NC Medicaid Providers?  More and more and more and more audits.

Remember the ant in the “Ant and the Grasshopper?” If not, here is the fable.

Quick Synopsis: All summer long the grasshopper played while the ant dutifully collected food for the winter, while the grasshopper made fun of him.  Once winter came, the grasshopper had no food, and the ants says, “You should have thought of winter then!”

So, providers, be the ant!

HB 320: The Good News and the Bad News for NC Medicaid Providers

If you have been following my blog, then you know that I have been vehemently opposing House Bill 320. Well, the bad news is that HB 320 passed its 2nd reading today. The good news is that HB 320 has morphed from a  MCO-sovereign Bill into a more reasonable Bill.

Prior to the strike outs, HB 320 allowed

  • 108D-10: The MCOs to conduct closed networks (i.e., disallowing providers into the networks);
  • 108D-11: The MCOs to select the providers allowed in the network;
  • 108D-13: The MCOs to conduct unannounced on-site visits, post-payment reviews and any other allowable function of Program Integrity;
  • 108D-15: The MCOs to suspend payments to providers (under certain circumstances);
  • 108D-16: The MCOs to require a provider to undergo prepayment review (i.e., suspension of Medicaid reimbursements for a period of time without an appealable right);
  • 108D-18: The jurisdiction for grievances against an MCO to be superior court, not OAH.

After the strike out, everything listed above is deleted.  Click here for the legislative history of HB 320.

Now, remember, this HB 320 is not law.  It is a proposal.  But the current revision with all the above-referenced deletions could mean a big win for health care providers.

In this case, I think the good news outweighs the bad.  But we shall see if the current revision remains….