Monthly Archives: August 2013

Big Change in Medicaid Audits? Or Just More Auditing Companies?

According to “Report on Medicare Compliance,” dated August 5, 2013, (Yes, I actually subscribe to this Report), the Center for Medicare and Medicaid Services (CMS) has BIG changes on the horizon for Medicare AND Medicaid audits (nationwide).

According to “New CMS Program-Integrity Plan Is In the Works; No More ZPICs, MICs,” CMS is developing a “unified program integrity strategy” that will consolidate some Medicaid and Medicare audits.

What does that mean to NC health care providers? Less audits? More audits?

Apparently, CMS intends to contract with 5 – 15 new “unified program integrity contractors (UPIC)…yes, another new acronym… The article also states that UPICs would replace zone program integrity contractors (ZPICs) and Medicaid integrity contractors and program safeguard contractors.

However, according to the article, the Recovery Audit Contractors (RACs) will remain in place. 

Companies wanting to act as UPICs were to respond to CMS by August 13th.  So these UPICs may be effective in the near future.

Are UPICS intended to streamline the audit process (by consolidating Medicare and Medicaid audits)?

Or will UPICS just add an additional 5 – 15 auditing companies, increasing the number of audits on providers, and weeding out providers willing to accept Medicaid to decrease Medicaid spending?

What is the Difference Between the 1915 b/c Waiver and Technical Guide?

Do you know the difference between the 1915 b/c Waiver and the Technical Guide?

You should!  (If you provide Medicaid mental health or substance abuse services or services to developmentally disabled persons).

What is the 1915 b/c Waiver (the “Waiver”)?

It is a document (a very large document) that all health care providers, recipients and State agencies must adhere to in order for Medicaid recipients to receive the medically necessary services needed.  The consequence of anyone in NC not following the Waiver? The feds can come and recoup Medicaid money…or perform any other allowable remedy/punishment.  Basically, everyone in NC (germane to Medicaid) must follow the Waiver or answer to the federal government.

The Waiver applies to Medicaid recipients suffering mental health issues, developmental disabilities, and substance abuse.

The Centers for Medicare and Medicaid Services (CMS) granted the North Carolina Waiver, which operates under Section 1915 (c) of the Social Security Act. This Waiver operates concurrently with a 1915 (b) Waiver, the North Carolina Mental Health/Developmental Disabilities/ Substance Abuse Services Health Plan (NC MH/DD/SAS Health Plan).

In sum, the Waiver is a document approved by the federal government (CMS). The Waiver applies to Medicaid recipients suffering mental illness, developmental disabilities and substance abuse.  We must adhere to the Waiver…or else.

So what is the Technical Guide?

First, what is it not? If the Waiver is Medicaid “law,” the Technical Guide is not.

When you were in high school, did you ever read Cliffsnotes?  You know, your English teacher assigns “The Great Gatsby,” but you have so many other important things to do in high school other than to read “The Great Gatsby.” So you get the Cliffsnotes.  Easy enough, right?

Until your teacher tests on details in “The Great Gatsby” that were not in the Cliffsnotes…

I am NOT (capital N.O.T.) comparing the Technical Guide to Cliffsnotes.  The Technical Guide is approximately 350 pages.  If Cliffsnotes were 350 pages long, then the actual book would be over 1000 pages.  If the Division of Medical Assistance (DMA) were attempting to draft an abridged version of the Waiver with the Technical Guide, then someone grossly misunderstood the word “abridged.”

DMA prepares the Waiver, and (although I have never been present for the process of its creation) I believe that DMA works extraordinarily hard on the Technical Guide.

Despite, DMA’s hard work, the Technical Guide, generally, is  not identical to the Waiver.

If the Technical Guide were identical to the Waiver, then the Technical Guide and the Waiver would be identical, right?

The Technical Guide is supposed to be a “user-friendly” rendition of the Waiver.  Because, folks, I am here to tell you, the Waiver is NOT “reader-friendly.”

But….beware….if it comes down to a legal argument in a court of law, the Technical Guide is not law…the Waiver is law.  So if you are having your employees read the Technical Guide in lieu of the actual Waiver, you MAY be in violation of the Waiver, even though you meet the Technical Guide criteria.

For example, in the Technical Guide, for authorization of In-Home Intensive Supports, for prior authorization, a Medicaid recipient could use (for prior authorization):

“Until the participant has a Supports Intensity Scale assessment [SIS assessment], the NC SNAP is used and the participant must have a score of at least 4 or 5 in Medical and/or Behavioral.”

According to the Technical Guide, a SNAP score can be used in order to receive authorization for In-Home Intensive Services.

However, the Waiver says nothing about a SNAP score.  According to the Waiver, the ONLY document that can be used for prior authorization for In-Home Intensive Supports is the SIS assessment.


Not the SNAP!

Ambiguity? I think so…

But, when the English teacher tests on the details of “The Great Gatsby” that were not found in the Cliffsnotes, you fail.

Similarly, when you only follow the Technical Guide, you may find yourself (legally) holding the “Cliffsnotes of the Waiver.”

And liable.

To Expand Or Not To Expand Medicaid: A Nationwide Draw?

Who likes a tie (or a draw) in sports? Not me!

In the last few years, I have noticed that, increasingly, parents of young children in sports are not keeping score.  You can go to a ten-year-old’s soccer game and ask the score, only to hear, “Oh, we don’t keep score.  We believe that everyone is a winner.”

Without stepping up onto my soapbox, let me just say I think “scoreless games” are as worthless as the nonexistent scores themselves.  I mean, come on, our country was founded on doing your best, working hard and receiving just compensation for hard work. (Not to mention that I grew up participating in competitive sports (gymnastics), and I truly believe that my participation in a competitive sport has contributed to my work ethic today).

Even Ashton Kutcher, during a recent Teen Choice Awards speech, surprised many with a speech about hard work and that opportunity looks a lot like hard work.

But, it is a different story when the teams actually keep score and the end result is still a draw.  When you keep score and the result is a draw, generally, that means that two teams with similar ability played and both played hard and both kept one another at bay.

Like the 1996 hockey game between Colorado Avalanche and Buffalo Sabres…both teams bragged it had the best goalie.  They played (and kept score) and recorded a shutout (0-0) tie game.  Apparently, both goalies were equally great.

Going to Medicaid expansion. That’s an old topic for North Carolina, right? But not for the U.S…

Yes, Governor McCrory nixed NC Medicaid expansion in NC.  Which, BTW, in my humble opinion, was a smart choice.  But, before everyone starts screaming cuss words at the computer screen, read my blog: Medicaid Expansion: Bad for the Poor.

But, remember, other states are still wrestling with the idea of Medicaid expansion.

Decisions are being made every day.  Just yesterday, Wyoming lawmakers announced that they were considering an alternative to Medicaid expansion. (As in, it would pretty much be Medicaid expansion, but named something else to avoid the appearance of concurring with the Affordable Care Act (ACA)).

So what is each state’s stance on Medicaid expansion?

Go figure….close to a tie.

Here is each state’s stance on Medicaid expansion as of July 26, 2013:


So the score is 28-22 (counting those states “leaning” as decided).  Not exactly a tie, but pretty close.

The tie is especially interesting when you consider that the “score” of Republican to Democrat governors in the U.S. is 30-20.


The red states denote Republican governors; the blue states elected Democratic governors.

Although, remember, 18 states still have not decided whether to expand.  Which means, the score could be 46-4 or 10-40.  Whew….neither of those scores is a tie!

So what does this “close to a tie” in Medicaid expansion mean? Especially with the majority of governors nationwide affiliated as Republicans…Anything?

Maybe not.

But maybe.

But, at least, we are keeping score.  At least both teams are playing to the best of its ability.  In the end, there will be a winner.

As there should be.

Hopefully, in the end, the winners will be the Medicaid recipients. (One can hope).

Medicaid Providers: Know What the “Way Back Machine” Is? Perhaps, You Should!

This blog pertains to all Medicaid providers regardless the state and regardless the Medicaid service provided.

Heard of the “Way Back Machine?”  Perhaps, you should have!!!


You are a Medicaid provider, and you get a Tentative Notice of Overpayment (TNO) based on a Medicaid post-payment review by Public Consulting Group (PCG) or HMS in the extrapolated amount of $800,000 based on a sample size of 100 dates of service (DOS) and multiplied out to some extrapolation universe. You look at the extrapolation data and determine tha you were not even paid $800,000 during the time frame PCG determined was the universe. Or you say…What???…My documents complied with policy!

What do you do?

Sound like a horrible SAT question? Or sound like reality?

Hopefully you answered the former, but if you answered the latter, read on…

You’ve read my blogs before and understand the importance of appealing PCG or HMS’ extrapolated audit.  But you do not have the financial means to hire an attorney.  Or you honestly believe that if the Department of Health and Human Services (DHHS) reviewed your documents that its employees would also agree that PCG or HMS was wrong.  Or you, personally, want to self-audit to determine the veracity of the audit.  Or for whatever reason, you want to know whether PCG or HMS was correct for your own well-being. 

How do you self-audit….the audit?

This may be one of the best “tips” I have given… (sorry for tooting my own horn, but, seriously, this blog can be helpful! I had a client that pointed out he/she had no idea about this “tip.”)

PCG and HMS conduct post-payment reviews.  This means that PCG and HMS are looking at 1-2-3-year-old medical records.

Think about how quickly Medicaid changes.  Now think about the number of times in which the DMA Clinical Policy applicable to your practice has been revised in the last few years.

When I say DMA Clinical Policy, I mean, if you provide Outpatient Behavioral Therapy, Policy 8C is applicable.  If you provide dental services to Medicaid recipients, then Policy 4A is applicable.  If you provide durable medical equipment (DME) to Medicaid providers, then Policy 5A is applicable.  For a full list of the NC Medicaid policies, please click here.

The DMA Clinical Policies change significantly throughout the years.  For example, DMA Clinical Policy 8A, revised January 1, 2009, allowed Community Support for adults and children.  Yet Policy 8A, revised August 1, 2013, does not even allow Community Support (obviously Community Support was disallowed prior to August 2, 2013, but I am making a point).  Also, now we have 16 unmanaged outpatient behavioral therapy visits for children, whereas a couple of years ago we had 26 unmanaged visits.

The point is that when PCG or HMS audits your particular service, the auditors are not always experts in your particular service, nor experts in your particular service’s Clinical Coverage Policy.  See my blog on Dental Audits Gone Awry.  In this blog I show the required (or lack thereof) education/experience to become a PCG auditor.

Therefore, it is imperative that you have access to the applicable Clinical Coverage Policy applicable for the DOS audited.

But, if you google 2009 clinical policy for NC Medicaid dental services, you can’t find it.

So how are you supposed to get access to these old policies that are being used (or mistakenly NOT being used) in Medicaid audits for the older DOS?

It is called: The Way Back Machine.

I know, cheesy!  But I did not name it.

The “Way Back Machine” website looks like this:

Way Back Machine

The beauty of the “Way Back Machine” is that you can go to any current website.  Copy the internet address.  Paste that internet address into the “Way Back Machine” where you see “Way Back Machine” and a white box appears in which to type the website address. Type in the address, and hit the button “Take Me Back.” VOILA…time travel!!!!

Small Tip: I have found that if I use the internet address for the specific policy for which I am researching, I am less successful than if I use the general DMA Policy address found here.  Once you get to the appropriate year on DMA’s general policy website, you can click on the specific policy in which you are interested.

Using the “Way Back Machine,” you can go to the DMA Clinical Policy (for whatever Medicaid service) applicable years ago.

You should never need to go more than 3 years back, as Recovery Audit Contractors (RACs) without permission by DHHS, cannot audit DOS more than three years ago.

But, you need to review the Clinical Policy for [fill-in-the-blank] Medicaid service 2 years ago? No problem! Use the “Way Back Machine” and travel back in time.

Wouldn’t it be great if we could travel back in time “for real?” Prior to RACS…prior to PCG…prior to HMS….? We need a “Way Back Machine” for Medicaid providers (and me) “for real!”

McCrory Signed SB 553: The Legal Burden is Now on Medicaid Recipients

August 23, 2013: Governor Pat McCrory signed Senate Bill 553.  Senate Bill 553 is now Session Law 2013-397.

No words can express my disappointment.

Starting Monday, Without a Veto, the Legal Burden of Proof Will ALWAYS Be on the Medicaid Recipients

I am not sure whether you have noticed, but Medicaid recipients have very little pull in North Carolina government.  Medicaid recipients have very little voice in our society.  Obviously, Medicaid recipients are indigent, so they do not have the money to hire lawyers and lobbyists. 

Politicians (while they are campaigning) always protest that they believe that Medicaid recipients are important…that Medicaid is important…but, most importantly, that it is important that Medicaid recipients receive quality health care….right?

We’ve heard the rhetoric over and over.

But then what happens when the politician takes office?

I can tell you what does NOT happen. Medicaid recipients do not band together, hire a lobbyist and begin influencing government policies.

Per norm, the Medicaid recipients remain invisible.  And mute.

I have a client with a daughter.  This daughter, we will call her Jennifer, is in her 30s, but with mentality of an 18-month old.  Jennifer is diagnosed with Tuberous Sclerosis Complex (“TSC”), a rare, multi-system genetic disease.  She is nonverbal and requires 24 hours/day supervision for health and safety and total care for activities of daily living and incidental activities of daily living, just as an 18-month old would require.

The Managed Care Organization (MCO), where Jennifer resides, is Smokey Mountain Center (SMC).  For the last 4 years in North Carolina (five years ago Jennifer resided in California), Jennifer has received 16 hours/day Medicaid. Once SMC went live and Jennifer’s yearly authorization was up for renewal, SMC reduced Jennifer’s services to 12 hours/day, thereby leaving a 4-hour gap in which Jennifer would be  unsupervised. (Shocking that the MCO did not want to foot the bill for the extra 4 hours, right?)

I will spare you the details of the legal arguments on both sides, as, today, my husband made a comment that my blogs were “too long.”

So, we are in the administrative hearing in front of an Administrative Law Judge (ALJ) with the attorneys for SMC and the Department of Health and Human Services (DHHS) present.  The ALJ asks me, “Counselor, who has the burden of proof, the Petitioner [us] or the Respondents [them]?”

To which I had to think back to my days during which I worked as an Assistant Attorney General (AG) for NC  (yes, I used to work on the other side…where do you think I learned this stuff?? At law school?)

For those of you without law degrees, the burden of proof (onus probandi, in Latin) is the obligation (hence the Latin word “onus“) on the party in a trial, who must prove [something] in court in order for the burden to shift to the other party to dispute.

Sometimes people will explain the burden of proof as “the necessity of proof always lies with the person who lays charges.”  As in, if you claim that I stole your watch, you must prove I stole it.  I do not have to prove that I did NOT steal it.

This may seem like ridiculous semantics to you, but, legally, who bears the burden of proof is huge.

In Jennifer’s example, the ALJ was asking me whether we (Jennifer) had to prove that she medically needed 16 hours/day Medicaid services or whether the State had to prove why Jennifer did NOT need the 16-hours/day Medicaid services.

If we (Jennifer) put on compelling evidence that she needed 16-hours/day services, and Respondents SMC and DHHS put on equally, compelling evidence that she did NOT need 16-hours/day services, then the Judge would have to rule against the party bearing the legal burden of proof.

As of today, here is the law as to burden of proof for Medicaid recipients:

(d) Burden of Proof. – The recipient has the burden of proof to show entitlement to a requested benefit or the propriety of requested agency action when the agency has denied the benefit or refused to take the particular action. The agency has the burden of proof when the appeal is from an agency determination to impose a penalty or to reduce, terminate, or suspend a previously granted benefit. The party with the burden of proof on any issue has the burden of going forward, and the administrative law judge shall not make any ruling on the preponderance of evidence until the close of all evidence.

(emphasis added). 

Senate Bill 553 will change all this.

Senate Bill 553 states that, “The enrollee has the burden of proof on all issues submitted to OAH for a contested case hearing under this section and has the burden of going forward. The administrative law judge shall not make any ruling on the preponderance of evidence until the close of all evidence in the case.”

The enrollee = the Medicaid recipient.

Therefore, even if the MCO terminates an enrollee’s services (and even if the termination is arbitrary and without merit), the Medicaid RECIPIENT bears the legal burden to prove this.

Really?  Let’s make it even harder for Medicaid recipients to appeal denials or reductions in services.  They can handle it!  They can hire a lawyer!  Right?

Who does this change benefit? Who benefits from the Medicaid recipients bearing the burden of proof in a legal action?

Answer? The MCOs.  And guess what?  The MCOs have lobbyists.  The MCOs have lawyers.

Senate Bill 553 was ratified July 26, 2013.  Which means that SB 553 will be law beginning Monday unless Governor McCrory vetoes the bill by Sunday.  On Sunday (August 25, 2013), McCrory can choose to sign SB 553, allow SB 553 to pass without his signature, or veto the bill.

If McCrory does NOT veto the bill, Medicaid recipients will bear the burden of proof in all contested cases. 

I ask you, why would we as a society place the legal burden of proof on the party LEAST likely to be able to afford a lawyer?

Send Gov. McCrory an email. Veto SB 553!!!

NC Medicaid: “A Modest Proposal for Medicaid Reform”

Medicaid recipients in North Carolina are not getting the same, quality health care that citizens with private insurance receive.

Health care providers refuse to accept Medicaid due to low, Medicaid reimbursement rates.  There are not enough Medicaid providers for all the Medicaid recipients.  Medicaid recipients have difficulty finding health care providers, especially dentists and other specialists. Many Medicaid recipients are forced to go to the emergency departments (EDs) for medical issues that could have been conducted in a primary care doctor’s office, thereby creating excessively long, waiting periods at EDs.  Medicaid recipients, who understand they need mental health services, are left to the whim of an employee at a managed care organization (MCO) as to whether the recipient meets medical necessity for a behavioral health care service.

I’ve blogged before that the disparity between the health care a Medicaid recipient receives and the health care a citizen with private insurance receives reminds me of the “separate, but equal” doctrine during the Civil Rights Movement. 

Medicaid recipients in North Carolina are not getting the same, quality health care that citizens with private insurance receive.

Separate is not equal!

As a nod to the great author, Jonathan Swift, I have “A Modest Proposal for Medicaid Reform.”  Jonathan Swift is probably more well-known for “Gulliver’s Travels,” but, by far, my favorite Swift work is “A Modest Proposal.”  With “A Modest Proposal,” Swift defined satirical writing, but about 300 hundred years ago. 

“It is a melancholy object to those who walk through this great town or travel in the country, when they see the streets, the roads, and cabin doors, crowded with beggars of the female sex, followed by three, four, or six children, all in rags and importuning every passenger for an alms. These mothers, instead of being able to work for their honest livelihood, are forced to employ all their time in strolling to beg sustenance for their helpless infants: who as they grow up either turn thieves for want of work, or leave their dear native country to fight for the Pretender in Spain, or sell themselves to the Barbadoes.”

Interestingly, Swift published “A Modest Proposal” anonymously in a newspaper.  At the time Swift wrote it, Ireland was in an impoverished state with an over-population problem.  Some lawmakers had suggested a number of population-control methods that, apparently, insulted Swift to his core.  One person suggested running the poor through a joint-stock company, presumably for the “rich, educated” people to control the “poor.”  Others suggested population-control, such as preventing childbirth for certain demographics.

Similarly, today I was listening to CNN when the newscaster explained that a mother of an autistic child received a hateful letter from a neighbor about her autistic child.   

Here are some statements found in the letter: (Please understand that these words are not mine.  In fact, when I heard this story, I was torn between crying for this mother and child or becoming infuriated at the ignorance and narcissistic hubris of the author).

The letter goes on to criticize Begley for allowing Max to play outside and says: “That noise he makes when he is outside is DREADFUL!!!!!!!!!! It scares the hell out of my normal children!!!!!!!”

The letter also tells Karla that she has a “retarded kid” and “should deal with it properly”.

“What right do you have to do this to hard working people!!!!!!!! I HATE people like you who believe, just because you have a special needs kid, you are entitled to special treatment!!! GOD!!!!!!”

The writer finishes by demanding the family “go live in a trailer in the woods or something with your wild animal kid!!!” and asks the family to do the right thing and move or “euthanize him. Either way, we are ALL better off!!!”

I hope that the above words impacted you as they did me.  I simply cannot believe that a person…any person….would THINK those words, much less write those words.  Has our society become so callous to people with special needs that the people with special needs have become (in the author’s view) burdensome or annoying?  To the author of that hateful letter, I say, “Shame on you!” 

I also say, “If there were laws against being heartless, you would be sentenced for life!”

In “A Modest Proposal,” Swift suggests (satirically) that the impoverished Irish might ease their troubles by selling their children as food for rich gentlemen and ladies. “This satirical hyperbole mocks heartless attitudes towards the poor, as well as Irish policy in general.”  See Wikipedia . (It amazes me that the authors of Wikipedia draft better English essays than I did in college).

According to DMA, in 1999-2000 more than 1.22 million individuals were covered under North Carolina’s Medicaid program.  By 2009, that number had grown to more than 1.81 million individuals, an increase of approximately 50%.  That means that 1.81 million people in North Carolina depend on Medicaid.  These are our neighbors; these are our children; this may even be us.

I have my own “A Modest Proposal.”  My “A Modest Proposal” is:

A Modest Proposal for Medicaid Reform.”

Our Medicaid budget  is approximately $14 billion.  According to Kaiser, our Medicaid expenditures were $10,546,984,914 in fiscal year (FY) 2011.  However, Kaiser also notes that “expenditures do not include administrative costs, accounting adjustments, or the U.S. Territories. Total Medicaid [federal and state…as in, nationwide] spending including these additional items was $427.4 billion in FFY 2011.”

We spent $10.5 billion (estimated) on Medicaid services for Medicaid recipients in FY 2011.  According to the January 2013 State Audit of DHHS, in fiscal year 2011, North Carolina Medicaid incurred administrative expenses of approximately $648.8 million.  Now, here in 2013, with the MCOs in place statewide, I wager that the administrative costs for Medicaid for fiscal year 2013 will, at least, double due to the salaries and benefits awarded to MCO employees. 

67.4% of our $10.5 expenditure went to acute care (hospitals).  No shock there. Medicaid recipients generally do not receive continuity of care through a primary physician.  Therefore, many Medicaid recipients end up in the ED for an ear ache (ever wonder why the waiting period at the ED is so long?). 

Plus, North Carolina is, sadly, floundering as to providing mental health services, so it is no wonder that  “almost one-third of ED visits by those with underlying mental health disorders resulted in hospital admission, more than twice as many as those without underlying mental health disorders,” according to a new study released by North Carolina School of Medicine researchers.  For the study, click here.

28.8% of our Medicaid expenditure went to long-term care.  Again, not surprising with the rise of more aged, NC citizens.  Kaiser Family Foundation data for FY 2009 show that approximately 27% of those enrolled in the North Carolina Medicaid program were categorized as aged or disabled, and that the cost of services for those 2 categories of recipients made up approximately 63% of the program’s total costs that year.

3.9% of our Medicaid expenditures for 2011 went to DSH payments.  Disproportionate Share Hospital (DSH) adjustment payments provide additional money to hospitals that serve a significantly disproportionate number of Medicaid recipients.

3.9 + 28.8 + 67.4 = 100%

North Carolina’s total Medicaid spending including these additional items was approximately $11.149 million in FY 2011. ($10.5 billion + $648.8 million administrative costs). According to Beth Wood’s January 2013 Performance Audit, private contractor payments represent about $120 million (46.7%) of DMA’s $257 million in administration expenditures for FY 2012.  Almost half of the administrative costs for Medicaid, in 2012, went to contracted companies, such as Piedmont, Carolinas Center for Medical Excellence (CCME), Public Consulting Group (PCG), etc…

So…here is my “A Modest Proposal:”

If you take the total Medicaid budget (currently, over $14 billion) for the fiscal year ended June 30, 2012, and divide the budgeted amount by 1.8 million (the approximate number of North Carolinians on Medicaid), you get: $7,777.78.

$7,777.78/year for each Medicaid recipient.

My health care premiums for a “Cadillac health care” with my husband costs $9000/year.  And it is great health care.  All copays are $10 for generics, $15 for non-generic.  Doctor visits are $10, a specialist is $25.  The beauty of my health care, though, is the deductible is only $500.  I hit $500, and everything is covered.

Now, mind you, the $9000 ($750/month) includes my husband.  If I wanted individual insurance  it would only have cost $228/month or $2,736/year.  Why the addition of my husband increases the premium from $228 to $750, I have no idea, but it does. (He does not even have pre-existing conditions!!! In fact, he flatly refuses to visit a doctor unless pending death.  In my mind, he should have been cheaper than I).

As an individual, in order to pay for this “Cadillac” policy, you would have to pay $2,736/year.  Add in the $500 deductible and the total cost (barring unexpected and individual costs) would  be $3236. 

Our Medicaid budget allows each Medicaid recipient approximately $7,777.78/year. 

First, I propose North Carolina downsize 80-90% of the Division of Medical Assistance (DMA) and keep running a much smaller DMA for the sole purpose of determining yearly Medicaid eligibility, thereby cutting almost all administrative costs.  I also propose hiring ZERO contracted companies for Medicaid.  There is no reason for any contracted companies under my “A Modest Proposal for Medicaid Reform.”

17,000+ people are currently employed by Health and Human Services.  But employment of citizens is not a reason to maintain an agency.  Therefore, if we can manage Medicaid without 16,500 employees (which my “A Modest Proposal for Medicaid Reform” purports to do), then we are paying unnecessary administrative costs.

Secondly, taking the Medicaid funds, and, instead of paying administrative costs to DHHS, DMA, PCG, CCME, all the MCOs, we purchase excellent, quality private insurance for each Medicaid recipient.  We pre-pay the deductible for all Medicaid recipients.  We hand the Medicaid recipients a private insurance card that is “pre-paid” with no deductible.

A pre-paid, private insurance card!  With no deductible! (Because the deductible is paid).

No more doctors refusing Medicaid!  Think about it….all doctors would take the new “Medicaid,” because the recipients would have private insurors paying the full price for medical services. 

No more placing the burden of whether a recipient meets medical necessity for a medical service in the hands of DMA or a contracted company.  The private insuror would take on that burden and use the same standard of medical necessity as it does for all its consumers.  And why not? The insurance company is getting paid the same…

Medicaid recipients would get quality care just as if they were not Medicaid-eligible.  And isn’t that our goal? For the Medicaid recipients to be cared for just as well as if they were not Medicaid-eligible?

No more difficulty finding health care providers that accept Medicaid. Medicaid recipients would have the “Cadillac” Blue Cross Blue Shield just like I do.

No more excessively long, waiting periods at the ED! Medicaid recipients would benefit from continuity of care just like I do.  No need to go to the ED for an ear ache.  The primary care physician can tend to the ear ache.

No one would worry about Medicaid fraud anymore because, as to health care, everyone would be the same.  (So, we could also eliminate the need for Program Integrity).

No more Medicaid provider contracts, as all health care providers would accept the new “Medicaid.”

No more Medicaid recoupments.

I profess, in the sincerity of my heart, that I have not the least personal interest in endeavoring to promote this [Medicaid reform], having no other motive than the public good of my [state], by advancing our trade, providing for [Medicaid recipients], and giving some pleasure to the rich.

Think what an impact North Carolina would have on the nation if we were to implement my “A Modest Proposal for Medicaid Reform!!”

NC Medicaid Provider, “Yes, You Have a Case Against CSC,” and the Top 5 Reasons no Lawsuit is Pending Against CSC

62 days with no Medicaid reimbursements. Would you survive? Would your company survive?

Many providers are not surviving the switch to NCTracks.  Yet what do we hear from DHHS?  “NCTracks is on Track.”

Yesterday, during my lunch hour, I made a mad dash to the mall.  My daughter is starting 3rd grade tomorrow, and she was in dire need of some new jeans.

My phone rang as I was comparing the price of jeans.  Ann (short for anonymous) called.  She wanted to know whether I was bringing a class action lawsuit against CSC, the company that created NCTracks.  This is a common phone call for me.  Today, I received another phone call similar, but from Nanny (another short for anonymous). 

Both Ann and Nanny informed me that they run small, Medicaid provider companies.  Medicaid reimbursements constitute most of both Ann and Nanny’s companies’ income. 

Ann and Nanny have not been paid for Medicaid services rendered since June 20, 2013.  62 days ago.

Both want to pursue legal action.  And Ann and Nanny are not alone.  I have had approximately 25-35 Medicaid providers contact me since July 1, 2013, regarding bringing a lawsuit against CSC.

Do providers, who have not been reimbursed since June 20, 2013, have a legal cause of action against CSC?  I believe, yes.  Providers are entitled to prompt payments of Medicaid reimbursements.  In fact, per federal law, 90% of clean claims must be paid to providers within 30 days.  Obviously, 62 days is well-past 30 days.

My advice to providers who want to bring legal action against CSC?


BUT, understand what a lawsuit entails.  I have made a list below of the top 5 reasons, I believe, no lawsuit is pending against CSC now.  For those providers wanting to bring legal action, read the items below.  Make a reasoned decision as to whether a lawsuit is feasible for you.

So why is there not a lawsuit pending against CSC?

Here are the top 5 reasons a lawsuit is not pending against CSC:

(Disclaimer: I am neither pro nor con for bringing a lawsuit.  This blog is in no way an attempt to bring a lawsuit.  I am merely trying to inform providers as to what details need to be addressed before ever bringing a lawsuit.  In many cases, for the reasons stated below, a lawsuit is not feasible.  Each provider must make up its own mind as to whether a lawsuit would benefit them).

1. Lawsuits are expensive.

Except for plaintiffs’ lawyers, for the most part, attorneys require a retainer and are paid by the hour. 

A lawsuit against CSC would require:

  • Research for filing the complaint (Which venue is best? What defenses will CSC raise? What causes of action do we assert?
  • Drafting/Filing the Complaint
  • Defending against CSC’s Motion to Dismiss
  • Drafting Written Discovery
  • Taking Depositions (each deposition COULD run $10,000+)
  • Responding to Written Discovery
  • Defending Depositions
  • Hiring Expert Witnesses
  • Depositions of Expert Witnesses
  • Motions to Compel/Defense of
  • Motions for Summary Judgment
  • Defend CSC’s Motions for Summary Judgment
  • Pre-Trial Motions
  • Prepare for Trial
  • And probably much more

2. Lawsuits are the opposite of fast.

If you want an immediate remedy (such as getting paid for work rendered, a civil lawsuit for damages is not the way to go, at least, it should not be sole remedy sought).  An injunction may be the better approach…or taking the time to personally drive to NCTracks…

Think of this: After filing a complaint, the defendant gets 30 days (in state  court) to file a response; however, it is pretty standard for the defendant to request an extension.  Then the defendant gets 60 days to answer the complaint.  Filed concurrently with the defendant’s Answer, most likely, would be a Motion to Dismiss.  A hearing would have to be scheduled for the Motion to Dismiss, plus the legal briefs that would need to filed.  We are talking about 4-5 months before we even get into discovery.  Then written discovery and depositions over the course of 9 month to a year.  If trial is scheduled within the first year and a half, you have to understand that whoever loses will appeal…. You get the point….

3. Damages are….?

Here’s the problem with bringing a lawsuit against CSC. You file a complaint alleging over $10,000 in damages (the minimum amount of damages to meet jurisdictional requirements of Superior Court).  Then 1 day later, CSC pays 100% of your claims.

What are your damages?

It depends.  Have you had to terminate staff? Obtain loans and pay interest?  Close an office? 

Obviously, the above-referenced examples would be damages above and beyond the mere payment.  But if your only damages is nonpayment, you may want to re-think a civil suit for monetary damages.

4. Lawsuits are Time Consuming.

Not only are lawsuits time-consuming for the attorneys, but the plaintiffs also will need to devote time to the litigation.

5. Plaintiffs must be deposed.

If you bring a lawsuit, you have to be deposed.  I have never been deposed, but I have deposed enough people to know that depositions, generally, are not fun for the person deposed.

So there you have it.

“The Top 5 Reasons a Lawsuit is Not Pending Against CSC.”

Do you have a legal cause of action against CSC?  Most likely.  Are you entitled to prompt payments of Medicaid reimbursements?  Yes.

But before filing that lawsuit, remember what a civil lawsuit for monetary damages entails.  Make sure you are prepared! 

If you ARE prepared, GO FOR IT!!!!

“Dr. Fata and His Shadow:” Fata’s Attempt at Multiple Medicare Bones Results in Zero

Recently a Michigan physician was arrested for committing over $35 million in Medicare fraud. (Probably some Medicaid fraud too, but Medicaid payments have not been reviewed).  I have always said in this blog that I am against fraud.  When someone is committing Medicare or Medicaid fraud, I say, prosecute to the highest degree allowable by law!

Here is one of many articles: link.

Providers who commit fraud are making good providers undergo  harassing audits, harsh recoupments, and needless attorneys’ fees to fight the injustices. 

Dear DHHS, This (the below-referenced story) is what Medicare/caid fraud looks like. It is obvious. It is disgusting.  Fraud is NOT forgetting to date a service note.  Fraud is NOT inadvertently inserting the incorrect billing code.  Stop focusing on documentation nit-picking and find the REAL fraud! From, Me.

But, this Michigan physician…of all the possible fraudulent Medicare/Medicaid schemes….this man takes the cake.

Dr. Farid Fata, an oncologist, falsely diagnosed people WITHOUT cancer (healthy adults) as having cancer, subjecting these healthy adults to chemotherapy, and reaping the monetary benefit of expensive procedures.  In my mind, Dr. Farid Fata should spend the rest of his life behind bars.  And, if possible, throw a little radiation in his cell every now and then.


If greed is the inordinate desire to possess wealth far beyond the dictates of basic survival and comfort and to the detriment of anyone else, Dr. Farat exemplifies greed.

Remember the moral: “It is not wise to be too greedy.” –Aesop.

This moral comes from “A Dog and its Shadow,” in which a dog crosses over a river with a bone in his mouth.  He sees his own shadow in the water, but shadow’s bone is twice the size of the bone in his mouth.  (Obviously, an optical illusion).  In an effort to snatch the bigger bone, the dog lets go of his own bone, and attacks the other dog (shadow), to get the bigger bone.  The dog loses both bones – the shadow-bone, because it is a shadow; and his own, because the stream sweeps it away.

Dr. Fata wanted his own bone, as well as any other bone he could possibly swipe.

In the meantime, Dr. Fata, in complete opposition of his Hippocratic Oath, injured hundreds of patients by subjecting them to unnecessary treatments. 

In the end, Dr. Fata loses all bones. 

What treatments did Dr. Farat perform?

  • Chemotherapy treatments to healthy adults;
  • Positron Emission Tomograph (PET) scans and a variety of cancer and hematology treatments for patients who did not need them;
  • The administration of unnecessary chemotherapy to patients in remission;
  • Deliberate misdiagnosis of patients as having cancer to justify unnecessary cancer treatment;
  • Administration of chemotherapy to end-of-life patients who will not benefit from the treatment;
  • Deliberate misdiagnosis of patients without cancer to justify expensive testing;
  • Fabrication of other diagnoses such as anemia and fatigue to justify unnecessary hematology treatments; and
  • Distribution of controlled substances to patients without medical necessity or are administered at dangerous levels.

Prosecutors say Fata was motivated by money, billing Medicare for false claims, all the while, living here:

Fata House

That is quite a bone!!!!

Dr. Fata faced a federal magistrate.  He was arraigned Monday on a federal health care fraud indictment.  Dr. Fata is being held at Wayne County Jail on a $9 million bond.

Dr. Fata became a naturalized American citizen in 2009.  He was a prominent oncologist.  Dr. Fata could very well had done well in his life with his wife with his own bones that collected.  Apparently, an oncologist-sized bone was not good enough for Dr. Fata.  Oh no, he wanted his oncologist-sized bone SUPER-SIZED.

And super-sized he will get!  He faces:

  • 20 years in jail;
  • Deportation (if any crimes occurred prior to 2009);
  • Possible bankruptcy;
  • Possible fines
  • Loss of his medical license;
  • Potential loss of family (If my husband intentionally committed these acts, I doubt I could ever stay with him…of course, my husband never would!!!)
  • Inevitable civil suits (If Dr. Fata diagnosed my with cancer and I discovered he purposely diagnosed me with a terminal disease to benefit monetarily….a very, large civil lawsuit would be filed immediately.  In fact, I am sure plaintiffs’ lawyers all over are salivating).

Yet, personally, I do not think the 20 years, even including all the incidental consequences, is enough punishment.  Think of the people who believed they suffered from cancer, underwent chemo, became ill (when they would otherwise have been healthy)…

The Italian poet, Durante degli Alighieri, simply referred to as “Dante,” in “Purgatory,” reserved the fourth circle of Purgatory for the greedy.  Also, some of the greedy were bound and laid face down on the ground for having concentrated too much on earthly thoughts.

In my mind, 20 years is not nearly long enough for Dr. Fata. 

Maybe, as Dante wrote, Dr. Fata should be bound and laid face down for 20 years.  Or, perhaps, he should  be forced to undergo years of chemotherapy…one year for every healthy adult he forced to undergo unneccessary chemotherapy.

Sandhills Center Marketing Closed Providers? Where is the Supervision?

A lady telephoned me today.  We will call her Dannae (because her name actually is Dannae, and she gave me permission to use her name).  Dannae used to have a company, Three-D’s Forever, Inc. d/b/a Step Down Group Home. 

Dannae used to manage a group home for mentally ill teens in the Sandhills catchment area.  Sandhills Center is one of our 11 (soon to be 10) MCOs and serves 8 counties: Anson, Harnett, Hoke, Lee, Montgomery, Moore, Randolph and Richmond. The eight county catchment area has a population of approximately 556,000 individuals.

From the time Sandhills Center (Sandhills) went “live” (contract effective date December 1, 2012, and “live” effective date April 1, 2013) until the day her company closed, May 3, 2013, Dannae and Step Down had difficulty dealing with Sandhills.

Throughout January 2013, Sandhills informed Dannae that forms were missing from the application; on or about February 8, 2013, Sandhills conducted a safety, site-visit check.  On or about February 17, 2013, Dannae received a letter from Sandhills saying the site visit was fine.

April 1, 2013, came and went and Step Down still did not have a contract with Sandhills.  She was told by Sandhills that everything had been approved and Step Down was on the list for approval.  Yet, Step Down had consumers in Sandhills catchment area with no Medicaid contract.  Numerous communications went back and forth. 

April 24, 2013, Sandhills contacted Step Down saying that it had been approved and a contract would follow.  But still…no signed contract.

Two check periods passed with no Medicaid reimbursements paid to Step Down.

The last contact from Sandhills was April 24, 2013, saying Step Down was approved.

Step Down was forced to close its doors May 3, 2013.

May.  It is mid-August.

Sadly, Dannae is now unemployed. Prior to May 3, 2013, she contributed to society.  She ran a business.  She helped Medicaid recipients.  Now, because of Sandhills and the bumpy (to say the least) transition to Sandhills, Dannae’s company is nonexistent.

Yet, I googled Sandhills’ Medicaid providers today.  An amazingly, long list of Medicaid providers is on Sandhills’ website as “Current Medicaid…Provider List.”  Here is the page in which I was interested:


I know. The print is small. But click on the picture and you can enlarge it. See Three D’s Forever, Inc d/b/a Step Down?

This is a list of Medicaid providers in the Sandhills catchment area that I pulled from today, August 19, 2013.  Three and 1/2 months after Step Down was forced to close, Sandhills still lists Step Down as a Medicaid provider.

Dannae told me that Medicaid recipients/guardians are still calling her for mental health care appointments because of Sandhills list of “current” providers.

Who is supervising Sandhills’ marketing of closed providers? Who is to say that Three D’s Forever, Inc. d/b.a Step Down is the only closed provider on Sandhill’s list?

Who is ensuring that Medicaid recipients have adequate access to mental health care?

Apparently not Sandhills, which, apparently, does not even know that Step Down is out of business.  Surely, not the Department of Health and Human Services (DHHS), because after the MCOs went live, DHHS cannot even track mental health services.  DHHS has no idea who is getting or not getting services.  The providers certainly cannot ensure adequate access.  Once the providers go out of business, the owners are concerned about their own monetary situations (and understandably).

This leaves the Medicaid recipients’ guardians, if applicable, who pull up the Sandhills current Medicaid provider list and start calling around.  They call Step Down only to be told Step Down is closed. 

How many other providers on Sandhills’ list are closed? Or no longer accepting Medicaid?

Wasn’t Sandhills contracted to manage behavioral health Medicaid care in 8 counties?

Then how can Sandhills be oblivious to the fact that a provider on its “Current Medicaid…Provider List” is closed?

As for Dannae, whether Sandhills is managing Medicaid behavioral health car within 8 counties adequately enough is a non-issue.  Her company is closed.  

She is just another victim of State non-oversight.