NC Medicaid: Are New Mexico and NC Medicaid Providers Fraternal Twins? At Least, When It Comes to PCG!

North Carolina and New Mexico? Fraternal twins?  Remember Arnold Schwarzenegger and Danny Devito?

I don’t know about you, but I imagine New Mexico is as identical to North Carolina as chicharrones are to grits. And I can only imagine what New Mexicans think of us. The words “redneck,” “chewing tobacco,” and “backward” come to mind, although being born and raised in NC, I would take vehement objection to those stereotypes. Regardless, as polar opposite as New Mexico and North Carolina may or may not be, we have at least one commonality. Public Consulting Group (PCG).

Since I posted my blog: “Even New Mexico Identifies PCG Audits as “Unreliable!”” I have had the pleasure of speaking to a number of New Mexicans (although one sounded, surprisingly, British). 

Here is what I have learned:

1. PCG is equally as inept in New Mexico as here. No explanation needed.

2. NM  has no administrative remedy for providers.  Whereas, we can request a reconsideration review with the Department of Health and Human Services (DHHS) when providers receive an outrageous Tentative Notice of Overpayment (TNO) from PCG, and, ultimately, appeal the DHHS decision to the Office of Administrative Hearings (OAH), apparently (remember I have never taken the Bar in NM, so if a NM lawyer would like to explain, I would be much obliged) there is no administrative process in NM. So, it seems, that the NM providers have to file an injunction in state or federal court to cease PCG’s erroneous auditing. Ugh!

3. In NM, PCG is freezing funding. So, in NM, PCG is acting similar to what may occur if you squished PCG and CCME together. Could you imagine? PCG and CCME merging? I shudder at the thought.

4. The suffering of Medicaid providers is not limited to state lines. New Mexican providers who accept Medicaid are suffering as much as NC providers who accept Medicaid are suffering. 

As I informed my blog readers a couple of days ago, 15 behavioral health providers  in NM filed an injunction against the State and PCG staying the providers’ frozen Medicaid funds. Now the NM State Auditor (our Beth Wood) will be reviewing the “special audit” that, supposedly, contains evidence of alleged overcharging, etc. by the 15 providers. (The special audit is the basis for the providers’ frozen funds….kinda like being on prepayment review, huh?).

Here is the article:

[New Mexico] State Human Services Secretary Sidonie Squier has refused to give State Auditor Hector Balderas a copy of the special audit that she says found evidence of alleged overcharging and possible fraud on the part of 15 behavioral-health providers. But on Tuesday, Balderas got a state district judge to subpoena the audit.

Meanwhile, on Wednesday a federal judge in Albuquerque heard arguments by lawyers for Human Services and eight of the providers whose Medicaid funding was frozen because of the special audit. The eight firms are seeking an injunction to force Human Services to resume payments to the providers. However, U.S. District Judge Christina Armijo took no immediate action on the request.

“It is necessary that my auditors fully review the report issued by Public Consulting Group Inc. in order to assess the risks to public funds and the potential impact on the Human Services Department’s financial affairs,” Balderas said in a written statement. “I formally requested the report from Secretary Squier pursuant to state law, but unfortunately the Department refused to comply with my lawful request. I am disappointed that I have been forced to take legal action to prevent the obstruction of a thorough audit of these taxpayer dollars.”

Public Consulting Group, a Boston company, was paid more than $3 million to audit the providers.

In a July 11 letter to Squier, James Noel, lawyer for the State Auditor’s Office, said the State Audit Act requires his office to “thoroughly examine and audit the financial affairs of every state agency.”

Noting that Human Services has said the special audit showed credible evidence of fraud, Noel said the department is required to “report immediately, in writing, to the state auditor any violation of a criminal statute in connection with financial affairs.”

Squier on July 12 responded in a letter to Balderas saying she was declining to release the audit to him.

“At this time no determination has been made that any individual or entity violated federal or state criminal statue, nor does [Human Services] have the authority to make such a determination,” the letter states.

Of the federal laws and regulations that require the department to turn “credible evidence of fraud” over to the state attorney general for investigation, Squier said, “Such a referral is not a finding of fraud by this agency.” She said she had to decline Balderas’ request because it could jeopardize the state attorney general’s investigation.

State District Judge Sarah Singleton of Santa Fe on Tuesday signed a subpoena requiring Squier to permit the state auditor to inspect the Public Consulting Group audit at 10 a.m. Monday.

Department spokesman Matt Kennicott said Wednesday that Squier and department lawyers will have to look over the subpoena before deciding on their course of action.

Earlier in the week, Rep. Stephen Easley, D-Santa Fe, and Sen. Benny Shendo, D-Jemez Pueblo, chairmen of a legislative subcommittee on behavioral health, delivered a five-page letter to Balderas requesting his office examine the Public Consulting Group audit. The letter raised issues including the role of OptumHealth, the company in charge of overseeing the behavioral health providers, and how the five Arizona companies — with which the state is contracting to take up the slack of the providers under investigation — were chosen.

On Tuesday, Gov. Susana Martinez told reporters that the Arizona companies were chosen because they have done similar work before. “They’ve been able to pick up services when there have been problems in other states, where there have been other allegations of fraud or misuse or mismanagement,” she said. “We want to make sure those patients have quick access.”

Does it matter to you, my reader, that all this hullaballoo is occurring on taxpayer money? And Medicaid state and federal money. Our tax dollars are paying PCG.

About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on July 18, 2013, in Administrative Remedies, Beth Wood, DHHS, Division of Medical Assistance, Health Care Providers and Services, Injunctions, Lawsuit, Legal Remedies for Medicaid Providers, Medicaid, Medicaid Audits, Medicaid Billing, Medicaid Recoupment, North Carolina, OAH, Office of State Auditor, PCG, Post-Payment Reviews, Public Consulting Group, RAC, RAC Audits, Regulatory Audits, Tax Dollars, Tentative Notices of Overpayment and tagged , , , , , , , , , , , , , , , , , , . Bookmark the permalink. 6 Comments.

  1. Linda Francis

    Knickole, do you know if letting a therapist bill MediCARE (or Medicaid) “incident to” raise risk of audit?

    -Linda (Sent from my iPhone)

  1. Pingback: Fraternal Twins - How to have Twins

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  3. Pingback: Because of PCG Audit, New Mexico Freezes Mental Health Services! | medicaidlaw-nc

  4. Pingback: Traveling to New Mexico: Another Administrative Action with PCG | medicaidlaw-nc

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