“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’ —> http://en.wikipedia.org/wiki/Sergei_Pankejeff)

 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 —> http://en.wikipedia.org/wiki/Emil_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 —> http://en.wikipedia.org/wiki/Dialectical_behavior_therapy).

 …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 (https://medicaidlawnc.wordpress.com/2013/05/17/large-number-of-nc-mental-health-providers-no-longer-accepting-medicaid/).

 In my private practice I found that these regulations caused the ’80-20 Rule’ (http://en.wikipedia.org/wiki/Pareto_principle) – 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

About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on May 31, 2013, in Behavioral health, Health Care Providers and Services, MCO, Medicaid, Medicaid Recipients, Medicaid Recipients Under 21, Mental Health, Mental Illness, North Carolina, Outpatient Behavioral Health, Post-Payment Reviews, Prepayment Review, Provider Medicaid Contracts, RAC Audits, Termination of Medicaid Contract and tagged , , , , , , , , , . Bookmark the permalink. 1 Comment.

  1. Trick question, this, “If Freud accepted NC Medicaid.”

    Answer is: don’t accept any ‘only Medicaid’ patients. This becomes very problematic re: children and adolescents. So, if that’s your population—mainly—good luck. Unless, that is, they are disabled children or adolescents and I can’t say I have ever seen that applied to that population. Best I understand, you can only file for disability come age 21…maybe age 18….and if the person is savy, they apply for disability under the Social Security number of a parent so that they receive Social Security Disability rather than just SSI which is only linked to Medicaid. SSDI is linked to Medicare.

    But I digress and its a long story. See my blog for more info: http://madame-defarge.blogspot.com/

    For someone working mostly w/ adults, I accept only patients who are dually eligible e.g., Medicare and Medicaid, w/ Medicare being primary.

    And BEWARE HUMANA. As of Jan 1, 2013, ALL, best I can tell, Humana clients (previously and still claiming to be a Medicare Advantage company) require the provider to be ‘in network.’ So, even though I have been a Medicare provider for years and in years previous there was no difficulty, now Humana is requiring the provider to create another tier of paperwork, utilizing CAQH information plus pages and pages of paperwork. If the provider is not in the Humana network, the client must plow thru $500 deductible before some of the mental health benefits kick in. With Medicare, at the beginning of every year, there is a $200 deductible that clients must plow thru. Given that I work with an indigent population, I just write it off. I have an inquiry at CMS awaiting an answer to this discrepancy. See my blog for info on that also.

    Currently, I have several patients that some agency e.g., ACT teams usually, slurps up the Medicaid. Me: I only stick to the Medicare.

    If Obamacare had been allowed by the Republicans to work as it needed to, there would be only one efficient insurer and that would be Medicare. Thank the lobbying power of the private companies for the mess we’re in and than the Republicans for continuing to balk at tweaking Obamacare.

    And trick to Medicare is to utilize the Health & Behavior codes e.g., 96152 series (if you do not know these codes, google up American Psychological Association and H & B codes: been in place since 2000 and happened due to APA). They pay at the medical 80% level rather than the psychiatric 50% level. They require you to submit the NPI of the primary care provider re: billing. They require you to overview and create ‘correspondence’ re: health matters. In other words, this is a code you use that is associated with a more holistic perspective associated w/ the client. These codes were not recently changed as were the other CPT codes.

    If Medicare and Medicaid ever get linked, I’m screwed.

    Marsha V. Hammond, PhD, Licensed Psychologist, Asheville, NC
    NC Mental Health Reform blog since 2007: http://madame-defarge.blogspot.com/

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