NC Medicaid: CCME’s Comedy of Errors of Prepayment Review

For those of you who have been on prepayment review or know someone else who has undergone prepayment review, this is for you.

Remember “A MidSummer’s Night Dream,” by William Shakespeare?  The comedy of errors? Undergoing a Medicaid audit performed by the Carolinas Center of Medical Excellence (CCME) is much like the comedy of errors in “The MidSummer’s Night Dream.”  (MSND)   And much like the events in MSND, everyone involved wants to believe that the audit was just a dream/nightmare, but, sadly, this is real life.

For those of you that were not forced to read MSND in school or did not study Shakespeare in college, MSND portrays the events surrounding the marriage of the Duke of Athens, Theseus, and Hippolyta. These include the adventures of four young Athenian lovers and a group of six amateur actors, who are controlled and manipulated by the fairies who inhabit the forest in which most of the play is set. In my humble opinion, the best characters in MSND is Titania and Puck.  Titania is the Queen of the fairies, who is estranged from her husband Oberon because Titania will not give her “changeling” to her husband.  Oberon wants the “changeling” to use in battle, but Titania will not have it. Puck is the court jester, who creates a magic flower that, if struck on a person with Cupid’s arrow, will make the struck-person fall in love with whomever or whatever is first seen upon awakening.

So Oberon devises a plan to use the magic flower on Titania and, while she is awe-struck with whatever or whomever she loves, Oberon will take the “changeling.” Puck strikes Titania with the flower, using Cupid’s arrow, and she is fast asleep.

Meanwhile a group of people are creating a play.  Nick Bottom, whose name Puck decides is another word for “jackass,” is one of the actors.  While Bottom is rehearsing, Puck transforms Bottom’s head into a jackass’ head.  Bottom has no idea and goes about his rehearsal with an ass head.

Titania wakes up, sees the ass-headed Bottom, and falls in love.  While she is in love with the ass-headed Bottom, Oberon takes the changeling.

In CCME’s very own comedy of errors, CCME conducts prepayment reviews for the Division of Medical Assistance (DMA). But in this comedy of errors, the provider (Titania) has its Medicaid contract (changeling) that DMA (Oberon) wants.  DMA (Oberon) sends CCME (Puck) to conduct a prepayment review (the magic flower) to get the Medicaid contract. The provider (Titania) becomes so confused and so frustrated with the process that, when she wakes up from the nightmare of prepayment review, she feels like an ass and has no Medicaid contract (changeling).

Here is CCME’s Comedy of Errors:

On August 6, 2012, Jane Doe receives her notice of prepayment review from CCME.  Jane also receives CCME’s first requests for documents for Medicaid recipients for certain dates of services (DOS).  In actuality, CCME requests hundreds of documents for multiple Medicaid recipients and multiple DOS, and, of course, Jane is given 15 days in which to comply.  But, for the sake of this blog and simplicity, we are going to concentrate on one Medicaid recipient and 3 DOS.

On October 10, 2012, Jane receives a request for documents for Medicaid recipient X for DOS 9/20/12, 9/24/12, and 9/27/12.

Jane complies.  She sends all the documents required to CCME. Remember, since August, Jane has not received any reimbursements for Medicaid, but Jane is expected to continue to service her clients, pay her staff, pay herself, and pay all overhead for her office without getting paid.  I wonder how many other professions would put up with continuing to work without payment.  I expect that if I went to the grocery store, put a bunch of food in my  cart, and tell the cashier that I am not paying until the state government performed an audit of the quality of its food, that I would be arrested for shoplifting.

In November, Jane receives a “Final Document Request” for Medicaid recipient X and DOS 9/20, 9/24, and 9/27.

The only item CCME requests in the signature log of Jane’s staff for all 3 DOS.  So, she sends in the signature log.  Implicit in the Final Document Request is that, since CCME only requested a signature log, that CCME had all other necessary and required documents for these DOS.

In December (remember Jane still had not received any Medicaid payments since August), Jane receives a denial for DOS 9/20, 9/24, and 9/27.  A denial means Jane does not get paid.  According to the denial, DOS 9/20, 9/24, and 9/27 were denied because CCME did not have a treatment plan, signed authorization by the Medicaid recipient, or the service note.  What????

1. Jane sent the treatment plan, the signed consent, and the service note back in October.

2. The Final Document Request only asked for the signature log.  Why didn’t the Final Request request the treatment plan, signed consent, and service note?

The comedy of errors continue.

In January 2013, CCME sends another Request for Documents.  Included in the list of required documents to be sent to CCME are documents for Medicaid recipient X for DOS 9/20, 9/24, and 9/27.

Jane thinks this is odd, but who is she to question the Medicaid auditor?  Plus, if she calls CCME to point out the repetitive nature of the audit, she is just told to comply with the audit.

So she does.  She re-sends all the required documents again.

A week later, she receives another request for DOS 9/27 for the same Medicaid recipient.  She re-re-sends the documents.

In February, she receives denials for DOS 9/20, 9/24, and 9/27.  A week later she receives the third denial for DOS 9/27.

A few days later, after calling CCME, getting transferred to 40 different people, and her repeated request for a copy of her compliance accuracy rate, CCME sends her accuracy rate to her.  CCME determined that Jane’s accuracy rate is 1.25% (you have to get over 70% for 3 consecutive months to pass prepayment review).  DMA terminates her Medicaid contract.

Due to the sequence of events, which I have called the comedy of errors, DMA (Oberon) successfully usurps Jane’s Medicaid contract (the changeling).

I doubt Shakespeare contemplated his “comedy of errors” template would be used in the Medicaid system. And Shakespeare’s version was much funnier.

About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on June 2, 2013, in CCME, DHHS, Division of Medical Assistance, Harassment, Health Care Providers and Services, Medicaid, Medicaid Audits, Medicaid Contracts, North Carolina, Prepayment Review, Provider Medicaid Contracts and tagged , , , , , , , , , , . Bookmark the permalink. 7 Comments.

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