Monthly Archives: October 2013

NC Medicaid Providers, Are You Required to Seek an Informal Appeal Prior to Filing a Contested Case at OAH?

Recently, numerous clients have come to me asking whether they have the right to appeal straight to the Office of Administrative Appeals or whether they have to attend informal appeals first, whether the informal appeal is within a managed care organization (MCO), the Division of Medical Assistance (DMA) or any other entity contracted by DMA.

The answer is: No, you are not required to go through the informal review prior to filing a contested case at OAH, but, in some cases, the informal review is beneficial.

Let me explain.

N.C. Gen. Stat. 150B-22-37 (Article 3) applies to:

“[A]ny dispute between an agency and another person that involves the person’s rights, duties, or privileges, including licensing or the levy of a monetary penalty, should be settled through informal procedures. In trying to reach a settlement through informal procedures, the agency may not conduct a proceeding at which sworn testimony is taken and witnesses may be cross-examined. If the agency and the other person do not agree to a resolution of the dispute through informal procedures, either the agency or the person may commence an administrative proceeding to determine the person’s rights, duties, or privileges, at which time the dispute becomes a “contested case.”

N.C. Gen. Stat. 150B-22.

“Any dispute between an agency and another person”…Obviously DMA is a state agency, but is Public Consulting Group (PCG)?  Is the Carolinas Center for Medical Excellence (CCME)? East Carolina Behavioral Health?  HMS?

What if you disagree with a prepayment review result that CCME conducted?  DMA had nothing to do with the actual prepayment review.  Can you bring a contested case at OAH against CCME?

Yes.  But include DHHS, DMA as a named Respondent.  If you include the state agency that contracted with the entity, then jurisdiction is proper at OAH.  The argument being that the actions of a contracted entity is imputed to the principle (DMA).

“Should be settled through informal procedures…”  Notice it states “should,” not “must.”  Time and time again when a provider skips the informal review within the entity (for example, let’s say that MeckLINK terminates Provider Jane’s Medicaid contract and files a grievance with OAH instead of through MeckLINK first) the counsel for the entity (MeckLINK in this example) argues that OAH does not have jurisdiction because Jane failed to exhaust her administrative remedies.  As in, Jane should have appealed through MeckLINK first.

In my opinion, appealing to the very entity that is causing the grievance is futile.  The decision was made.  The entity is not going to rule against itself. 

Plus, there is no requirement for any petitioner to exhaust informal appeals prior to appealing to OAH.  When you receive a Tentative Notice of Overpayment from PCG, you can go to an informal review or you can appeal in OAH. 

The “failing to exhaust administrative remedies” argument is being misapplied by the entities.  In order to file judicial review in Superior Court or a declaratory judgment action in Superior Court, you must exhaust all administrative remedies prior to seeking relief in Superior Court.  But the requirement to exhaust administrative remedies is not applicable to filing at OAH.

The upshot is that any person aggrieved may bring a contested case in OAH without attending an informal appeal first.

However, there are some occasions that, in my opinion, the informal appeal is useful.  Such as an overpayment found by PCG.  If you receive a Tentative Notice of Overpayment by PCG, the informal reconsideration review at DMA can be helpful for a number of reasons.

1.  It forces you to review the audited documents with a fine tooth comb prior to getting in front of a judge.

2. It allows you to find all PCG’s mistakes, and there will be mistakes, and bring those mistakes to the attention of the auditor.

3.  It gives you a chance to decrease the alleged amount owed before a contested case.

Keeping those positive aspects in mind, most likely, the reconsideration review will NOT resolve the case.  Although it has happened occasionally, more times than not, you will not agree with the reduced amount the DHHS hearing officer decides.  The alleged overpayment will still be extrapolated. The alleged overpayment will still be ridiculous.

Other than an overpayment, I have found very little use for the informal appeals.

DHHS’ Robotic Certification of MCOs…So Stepford-ish!

Senate Bill 208, Session Law 2013-85, requires the Secretary of the Department of Health and Human Services (DHHS) to conduct certifications to ensure the effectiveness of the managed care organizations (MCOs), and the first certification was to be before August 1, 2013.  N.C. Gen. Stat. 122C-124.2 was added as a new section by Session Law 2013-85 and states:

“In order to ensure accurate evaluation of administrative, operational, actuarial and financial components, and overall performance of the LME/MCO, the Secretary’s certification shall be based upon an internal and external assessment made by an independent external review agency in accordance with applicable federal and State laws and regulations.”

In order to comply with the statute, Secretary Wos conducted the first certification and published the findings July 31, 2013.  Well, actually Carol Steckel signed the certification and sent it to Sec. Wos (technically Wos did not conduct the certification, but she certified the content).

Steckel’s certification states that “DMA is attesting that all ten [MCOs] are appropriate for certification.”

Strong language!

Attest means to provide or service as clear evidence of.  See Google.  Clear evidence?  That the MCOs are compliant?

One of the areas that was certified was that the MCOs are timely paying providers, that the MCOs are accurately processing claims, and that the MCOs are financially accurate (whatever that means).

Here is the chart depicting those results:

Compliance chart2

Wow.  Who would have guessed that East Carolina Behavioral Healthcare (ECBH) is 100% compliant as to timely payments to providers, 100% compliant as to accuracy of claim processing, and 100% compliant as to financial accuracy.  ONE HUNDRED PERCENT!! As in, zero noncompliance!!

I mean…Wow! Wow! Wow! Wow! Wow!

Have you ever read “The Stepford Wives?” The book was published in 1972 by Ira Levine. 

Basically, the main character, Joanna Eberhart and her husband move to Stepford, Connecticut (a fictional place).  Upon arrival, Joanna and spouse (I can’t remember his name, so we will call him Ed) notice that all the woman are gorgeous, the homes are immaculate, and the woman are all perfectly submissive to their husbands (how boring would that be??). As time passes, Joanna becomes suspicious of the zombie-like actions of all the wives.

She and her friend Bobbie (until Bobbie turns zombie-like) research the past of the Stepford citizens and discover that most of the wives were past, successful business women and feminists, yet become zombie-like.  At one point, they even write to the EPA inquiring as to possible contamination in Stepford.

After Bobbie turns zombie-like, Joanna fears that the women are changed into robots.  She decides to flee Stepford, but is caught and is changed into a robot.  The books concludes with Joanna happily and submissively walking the grocery store with a large smile and robotic movements, and another wife moving into Stepford.

That book coined the word “Stepford” to mean someone acting as a robot, submissive, or blissfully following orders.

I am not saying that the DMA certification was conducted as a Stepword wife…I am merely explaining that I was reminded of “The Stepford Wives” when I read the certification.  Maybe there is no analogy to be made…you decide.

Upon quick review of the certification, a number of questions arise in my mind.  Such as…didn’t anyone proofread this??? Under each graph, it states “Data is based on a statistical sample of Medicaid claims processed between February and May of 2013 for each LME-MCO.”  Data is???

Hello!…It is data ARE, not data is!!  Data are; datum is.

Besides the obvious grammar issue, I am concerned with the actual substance of the certification. 

Nothing is defined. (Not surprising for an entity that doesn’t know data are plural).  Except “compliant” is defined on the last page as “A finding of  “compliant” means that HMS found that the LME-MCO was compliant with the requirements set forth in SB 208.”  That is like saying, “Beautiful is hereby defined as whatever I say is beautiful.”  That is not a definition.

And HMS? HMS, as in, the company North Carolina hired as a Medicaid recovery audit contractor (RAC)?  I do not know if HMS the RAC and HMS the credentialing company is the same company…but the names sure are similar.

Speaking of RACs, going back to the basis of the data…”a statistical sample?” (Which is not defined?)  What is a statistical sample?  Is this a statistical sample like Public Consulting Group’s (PCG) in extrapolation audits?  From where does the sample come?

Looking at the timeliness of provider payments, the lowest percentage is CoastalCare.  At 93.06%.  But what does that mean?  That CoastalCare takes longer than 30 days to pay providers in 6.94% of cases?  And what is noncompliance?  80%? 20%?  Because where I went to school, a 93% is a ‘B.’ Yet 93%, here, is “compliant.”  Does “compliant” mean not failing?

What is “claims processing accuracy?”  Does that mean that ECBH was 100% correct in processing (or not processing) claims based on medical necessity (or failure to meet medical necessity)?  or, merely, that the process by which ECBH processes claims (regardless of whether the process abides by clinical policy), does not deviate; therefore ECBH is 100% compliant?

How does one determine 100% compliance?  Does this certification mean that between February and May 2013, Sandhills paid 100% providers timely.  That for 4 months, Sandhills was not late for even one provider?  Because Sandhills had 100% in relation to timely provider payments.  (Personally, I would be extremely hesitant to attest for any entity achieving 100% compliance.  How easy would that be to disprove?? A journalist finds one mistake and the certification loses all credibility).

The next chart demonstrates the MCO’s solvency.

Solvency

I have to admit…this chart makes very little sense to me.  The only information we get is that greater than 1.0 equals compliance.  If you ask me, being greater than 1 seems like a very low bar.

But, if greater than 1 equals compliance, then, applying Logic 101, the higher the number the more solvent.  I could be wrong, but this makes sense to me.

Using that logic, in February MeckLINK was N/A (not “live” yet).  March: 1.32.  April: 1.54. May: 1.80.  Tell if I’m wrong, folks, but it appears to me that MeckLINK, according to HMS and unknown data, that MeckLINK is becoming more solvent as the months pass.

And this is the same MCO that WFAE cited was using accounting tricks to remain in the black????

And the same MCO that, come March 1, 2014, must be acquired by another MCO?  And then there were 9

Under the chart demonstrating the “Solvency Review,” it states, “Data is (sic) base don financial information…”  Duh!! I thought we’d review employee personnel records to determine solvency!! (Although…that could be helpful because we could see employee salaries…I’m just saying…).

What the certification does not say is financial information from whom?  The MCOs? 

Secretary Wos: “Hey, Alliance, are you solvent?”
Alliance: “Yes, Secretary.”
Secretary Wos:  “Oh, thank goodness! I wouldn’t know what to do if you were not!!”

Going back to the finding of compliance means HMS determined compliance…Does that mean that HMS compiled all the data?  What about the intradepartmental monitoring team?  Does the intradepartmental monitoring team just authorize whatever HMS says it finds?  Almost…Stepford-like.

The letter from Steckel showing DMA’s attestation of all 10 MCOs being appropriate for certification says just that…DMA is attesting that all 10 MCOs are appropriate for certification.  No analysis.  No individual thinking.  Almost…Stepford-like.

Then the letter from Sec. Wos to Louis Pate, Nelson Dollar, and Justin Burr (legislatures) regurgitates Steckel’s letter.  Except Wos’ letter says “I hereby certify that the following LME-MCOs are in compliance with the requirements of NC Gen. Stat 122C-124.2(b).”

Again, no analysis.  No independent thinking.  Steckel’s letter is dated July 31, 2013; Sec. Wos’ letter is dated July 31, 2013.  Wos did not even take ONE DAY to verify Steckel’s letter.

Zombie-like.

Stepford-like.

What good is a statute requiring DHHS to certify the MCOs every 6 months if each certification is attested to by a Stepford??

Study Shows the ACA Will Not Lead Physicians to REDUCE the Number of Medicaid Recipients, Supply and Demand, and Get Me My Pokemon Cards!

A recent “study” by Lippincott, Williams, and Wilkins is entitled “Doctors Likely to accept New Medicaid Patients as Coverage Expands.”  (I may or may not have belly laughed when I read that title).  See my blog “Medicaid Expansion: Bad for the Poor.”

The beginning of the article reads, “The upcoming expansion of Medicaid under the Affordable Care Act (ACA) won’t lead physicians to reduce the number of new Medicaid patients they accept, suggests a study in the November issue of Medical Care, published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.”

The study was published October 16, 2013. (BTW: From what I can discern from the article, the title actually means that physicians will be forced to accept more Medicaid patients because there will not be additional physicians accepting Medicaid).  Odd title.

According to this study, the ACA will not cause doctors to reduce the number of Medicaid patients.  What does this study NOT say?  Nothing indicates that the ACA, which will allow millions more of Americans to become eligible for Medicaid, will cause MORE physicians to accept Medicaid.  Nor does the study state that the ACA will cause physicians to accept MORE Medicaid recipients.

Am I the only person who understands supply and demand?

Anyone remember the 1999 Toys.R.Us.com debacle? On-line shopping was just heating up.  I was in law school, and I, as well as millions of others, ordered Christmas presents on-line from Toys R Us.  I ordered a bunch of Pokemon trading cards for a nephew…remember those? Me either…I just bought them for my nephew.  Toys R Us promised delivery by December 10th. 

Toys R Us was, apparently, a very popular store that year, because Toys R Us is unable to package and ship orders in time to meet the December 10th deadline.  Nor could Toys R Us meet the deadline of Christmas.  Employees were working through the weekends.  About two days before Christmas, and just in time to create last-minute havoc during Christmas time, Toys R Us sends out thousands of emails saying, “We’re sorry.”

Obviously, Toys R Us was slammed by the media, and thousands of consumers were highly ticked off…including me.

I had to go to the mall (a place to which I detest going) on Christmas Eve (the worst day to shop of the entire year, except Black Friday, which I also avoid) to get my nephew a present.

Toys R Us learned its lesson.  It outsourced its shipping to Amazon.com, which, obviously, has the whole shipping thing down pat.

Hypothetical:

50 million people are currently eligible for (and receive) Medicaid services (these numbers are purely fictional, as I do not know the real numbers…I basically estimated 1 million per state, which, I am sure, is an underestimation).  Say there are 3.5 million physicians that accept Medicaid (70,000/state, which is probably a high estimation, when we are considering only physicians and not health care providers, generally). 

Our hypothetical yields 14.28 Medicaid recipients per physician.  Or a ratio of 14.28:1.

Media state that, if NC expanded Medicaid, that 587,000 more North Carolinians would be eligible for Medicaid if NC expanded Medicaid.

Using NC as a state average, 29.35 million more people would be eligible for Medicaid if all states expanded Medicaid (obviously not all states are expanding Medicaid, but, in my hypothetical, all states are expanding Medicaid).  This equals a total of 79.35 million people in America on Medicaid.

But….no additional physicians….

Because, remember, according to the Lippincott study, the upcoming expansion of Medicaid under the Affordable Care Act (ACA) won’t lead physicians to reduce the number of new Medicaid patients they accept.  But the ACA does not lead more physicians to accept Medicaid or physicians to accept more Medicaid patients.

This brings the ratio to 22.67:1.  8 1/2 new patients per one physican…and, BTW, that one physician may not be accepting new Medicaid patients or may not have the capacity to accept more Medicaid patients.  It’s a Toys R Us disaster!!!  No one is getting their Pokemon trading cards!!!

Why not? Why won’t the ACA lead more physicians to accept Medicaid?  Why won’t the ACA lead physicians to accept more Medicaid recipients?

Didn’t the ACA INCREASE Medicaid reimbursement rates?  Wouldn’t higher reimbursement rates lead more physicians to accept Medicaid and physicians to accept more Medicaid recipients???  I mean, didn’t you hear Obama tout that Medicaid rates would be increased to Medicare rates?  I know I did.

One average, Medicaid pays approximately 66% of Medicare reimbursement rates.  Obviously, every state differs as to the Medicaid reimbursement rate.

The ACA, however, slashes the Medicare budget by 716 million from 2013 to 2022.  The cuts are across-the-board changes in Medicare reimbursement formulas for a variety of Medicare providers, including hospitals, nursing homes, home health agencies, and hospice agencies.   Furthermore, the ACA creates the Independent Payment Advisory Board (IPAB), which is intended to determine additional Medicare reimbursement rate cuts. IPAB will be creating a new Medicare spending target; it will be comprised of 15 unelected bureaucrats.  The board will be able to make suggestions to Congress to reign in Medicare spending, and one of the biggest tools the IPAB has is cutting physician reimbursement rates.

It’s the old smoke and mirrors trick…We will raise Medicaid rates to Medicare rates…pssst, decrease the Medicare rate so we can meet our own promise!!

While I am extremely happy to hear that, at least according to the Lippincott study, the ACA will not lead physicians to reduce the number of Medicaid patients they accept, I am concerned that the ACA will not lead more physicians to accept Medicaid and physicians to accept more Medicaid recipients.

In fact, the study states that “[t]he data suggested that changes in Medicaid coverage did not significantly affect doctors’ acceptance of new Medicaid patients. “[P]hysicians who were already accepting (or not accepting) Medicaid patients before changes in Medicaid coverage rates continue to do so,” Drs Sabik and Gandhi write.  I bet the Drs. did not ask, “Would you continue to accept Medicaid, if you knew that your practice would endure more audits, post-payment reviews, possible prepayment reviews, and, in general, suspensions of reimbursements if anyone alleges Medicaid fraud, irrespective of the truth?”

Which tells me…hello…more Medicaid recipients, not more doctors!! Even if the physicians already accepting Medicaid COULD accept additional Medicaid recipient patients, each physician only has a certain amount of capacity.  To my knowledge, the ACA did not increase the number of hours in a day.  Supply and demand, people!!

Where are my Pokemon cards???!!!

NC Medicaid Providers: “Credible Allegations of Fraud?” YOU ARE GUILTY UNTIL PROVEN INNOCENT!!

“Credible allegations of fraud.”  What does that mean???

As it pertains to Medicaid, “credible allegations of fraud” was first introduced into law by the Affordable Care Act (ACA) in 2010.  The Centers for Medicare and Medicaid (CMS) issued its Final Rule February, 2, 2011, and the Informational Bulletin in March 2011.

As you can see, “credible allegations of fraud,” as pertaining to Medicaid, is a relatively new concept.  But what does it mean?  The ACA does not define “credible allegations of fraud.”

I know what “allegation” means.  I also know allegations are not always true.  I also know allegations can change your life. 

When I was a senior in high school, I had been dating my high school sweetheart for 2 years.  An acquaintance, and an apparently, mean-spirited girl, alleged that my boyfriend cheated on me with another girl.  I was so angered and so hurt that I called up my boyfriend immediately and broke up with him.  For weeks, my boyfriend hounded me, professing his innocence.  But I was not to be swayed.  I refused phone calls, avoided seeing him, and publicly disparaged him to my friends.  20 years later I saw him.  I asked him whether he had really cheated on me, knowing that he had no reason to lie now (he is married with 4 children; I am happily married with one child).  But I was just curious because that allegation that he had cheated changed both our lives.  I am not saying that had it not been for the allegation that he and I would be together…not at all…in fact, I am sure we would have eventually broken up.  The point is that the allegation that he cheated, for good or for bad, changed our lives.  And, to me, he was guilty based on the allegation.

20 years later I found out that the allegation was false.  He never cheated.  But his innocence did not change the consequences of the accusation.  He was guilty until proven innocent.

Similarly (and more importantly), a mere accusation that a Medicaid provider is undergoing abhorrent billing practices or committing Medicaid fraud, and without any proof, can change a provider’s life.  A mere allegation of fraud suspends a Medicaid provider’s reimbursements.  The consequence of which can be dire…You are guilty until proven innocent.  Just like my boyfriend.  The accusation alone made him guilty.

According to 42 C.F.R. 447.90, “This section implements section 1903(i)(2)(C) of the Act which prohibits payment of FFP with respect to items or services furnished by an individual or entity with respect to which there is pending an investigation of a credible allegation of fraud except under specified circumstances.”  FYI: FFP stands for Federal Financial Participation (or Medicaid reimbursements in the vernacular).

Section 1903(i)(2)(C) of the Social Security Act (SSA) states that no payments shall be paid to “any individual or entity to whom the State has failed to suspend payments under the plan during any period when there is pending an investigation of a credible allegation of fraud against the individual or entity, as determined by the State in accordance with regulations promulgated by the Secretary for purposes of section 1862(o) and this subparagraph, unless the State determines in accordance with such regulations there is good cause not to suspend such payment.”

But what does “credible allegation of fraud” mean? Where is the definition?  Not in the SSA.

On March 25, 2011, CMS issued an Informational Bulletin in which “credible allegations of fraud” is defined…sort of…

The Informational Bulletin states, “In the final rule, CMS provides certain bounds around the definition of “credible allegation of fraud” at 42 C.F.R. § 455.2. Generally, a “credible allegation of fraud” may be an allegation that has been verified by a State and that has indicia of reliability that comes from any source. Further, CMS recognizes that different States may have different considerations in determining what may be a “credible allegation of fraud.” Accordingly, CMS believes States should have the flexibility to determine what constitutes a “credible allegation of fraud” consistent with individual State law. However, a credible allegation of fraud, for example, could be a complaint made by an employee of a physician alleging that the physician is engaged in fraudulent billing practices,  i.e., the physician repeatedly bills for services at a higher level than is actually justified by the services rendered to beneficiaries. Upon State review of the physician’s billings, the State may determine that the allegation has indicia of reliability and is, in fact, credible. “

1. An allegation

An allegation by its very definition is “a claim or assertion that someone has done something illegal or wrong, typically one made without proof.” See Wikipedia.  Without proof!!!  Why without proof? Because an allegation is preliminary…an accusation…not a conclusion. Girl alleges my boyfriend cheated on me.

2. Verified by a State

Makes sense to need to be verified…

2. Indicia of reliability

Indicia? Indicia means “distinctive marks: indication.” See Dictionary.com.  Not quite sure what that means, but indicia of reliability does not sound like a very high threshold.  Nothing like preponderance of the evidence or beyond a reasonable doubt.  Could be as low a threshold as I applied when the girl alleged my boyfriend cheated on me.

3. Comes from any source

Are you kidding me?? So, if I were a Medicaid provider, my ex-husband, out of spite and hatred, could call up Patrick Piggott over at Program Integrity (PI) and accuse me of Medicaid fraud…or the disgruntled employee I fired….or my next door neighbor who is angry about the bush I planted on his property…you get the point.

Why is it important what the definition is of “credible allegation of fraud?”

As a Medicaid attorney, I represent Medicaid providers (duh).  The point is that I have seen the dire consequences, first-hand, to many, many a Medicaid provider accused of “credible allegations of fraud.”  Here are a few, real-life examples (names have been changed to protect the innocent):

  • Provider Leroy is accused of “credible allegations of fraud.”  Leroy is placed on prepayment review and all Medicaid reimbursements are suspended.  Leroy provides residential services (the people he serves actually live in his home because of severe mental illnesses).  Without Medicaid reimbursements, Leroy cannot pay the mortgage, his staff’s hourly wages, or anything else.  He acquires a $200,000 loan to help him through, and the interest is high.  He truly thinks that he will get off prepayment review and save his company and his Medicaid recipients from not having a home or Medicaid mental health services.  After 6 months of barely sliding by, Leroy receives a Notice of Termination terminating his Medicaid contract with the State.  (It is important to note that the termination was based of a faulty audit by an inept contractor).  He declares bankruptcy and all the Medicaid recipients are discharged to the homes that could not care for them in the first place.  The “credible allegation of fraud?” It came from a disgruntled employee.
  • Provider Lacey receives a Tentative Notice of Overpayment (TNO) in the amount of over $2 million based on “credible allegations of fraud.”  Provider Lacey (after her initial heart attack) hires Attorney Clueless.  Clueless appeals the TNO and gets the overpayment amount reduced to $1.5 million.  Lacey does not have $1.5 million and asks Clueless to appeal again.  Clueless fails to appeal the overpayment by the appeal deadline, and Lacey gets a judgment entered against her and her company.  Lacey’s husband is sick and tired of hearing about the Medicaid audit and abandons her and her two children.  Lacey declares bankruptcy.  Lacey used to support herself and her family.  Now North Carolina does.  The “credible allegation of fraud?” Lacey’s husband (apparently he had issues WAY before he left).
  • Provider Larry receives notice from a managed care organization (MCO) terminating his Medicaid contract based on “credible allegations of fraud” and demanding a $700,000 recoupment.  Larry also hires Clueless.  Clueless files a lawsuit against the Department of Health and Human Services (DHHS) and the MCO.  Clueless did some homework and actually makes a good argument in court.  But by the time Clueless gets to court, 4 months has passed and Larry racked up $50,000 in legal fees.  Larry can’t pay the attorney fees.  Clueless withdraws as counsel.  Larry goes bankrupt.  The 400 Medicaid recipients that his company serviced do not receive the health care needed.  The “credible allegation of fraud?” One of his own recipients receiving substance abuse services in a state of incoherence while on crack cocaine.
  • Provider Lucy receives notice from the Medicaid Investigative Department  (MID) that she is under criminal investigation based on a “credible allegation of fraud.”  Lucy does not have enough money to hire an attorney, so she opts for the public defender, who knows nothing about Medicaid and is also named Clueless.  The public defender did not even review Lucy documentation because she did not understand the complex system of Medicaid.  Clueless provided poor representation, and Lucy was sentenced to 5 years in prison.  Lucy said, “I was the first in my family to get a PhD and the first to go to jail.”  The “credible allegation of fraud?”  Her local competitor.
  • 15 providers in New Mexico, based on “credible allegations of fraud,” have their Medicaid reimbursements suspended.  The 15 providers cannot pay staff, rent on buildings, and other bills.  The State of New Mexico brings in Arizona providers to replace the 15 Medicaid providers.  The Arizona provider takes over the 15 providers’ buildings, most staff and all consumers.  The 15 providers are out of business.  Without a trial.  Without even reviewing the evidence against them.  Based on a mere allegation of fraud, 15 providers go bankrupt…lose their careers…are unemployed… The “credible allegation of fraud?” Unknown.

Remember “credible allegation of fraud” is preliminary, and, at times, without any proof, yet the consequences are dire. 

Innocent until proven guilty is a bedrock principle in the American justice system.  Yet, innocent until proven guilty does not apply to Medicaid providers.  Our founding fathers created the concept of innocent until proven guilty.  While innocent until proven guilty is not explicitly codified in the Bill of Rights, the presumption of innocence is widely held to follow from the 5th, 6th, and 14th amendments. See also Coffin v. United States and In re Winship.

Here’s the problem….presumption of innocence only applies to criminal law.  Even when the consequences of a civil action is so monumental, so dire, so irreparable, the presumption of innocence does not apply.

So “credible allegation of fraud?”  It does not matter what the definition is.  The fact is that if ANYBODY alleges a “credible allegation of fraud” against you, you are guilty.  You are my boyfriend who never cheated on me, but a girl alleged that he did cheat. 

No evidence…You are GUILTY based on the ALLEGATION of fraud!

Credible?

More Financial Pressure on Hospitals By 2013’s Legislative Medicaid Budget

Representative David Price spoke as the Keynote Speaker at the North Carolina Society of Health Care Attorneys annual meeting yesterday morning.  Since Representative Price was actually up in Washington D.C. during the shutdown, it was very interesting to hear him speak.  His opinion, as one would expect from his ideology, was that the shutdown was idiotic and unnecessary.

image

What I found interesting was how he described the relationships between congressmen and women today versus in the 90s.  Remember, he has represented NC in Washington for more than one decade.  He described the relationships, even across party lines, as more cordial in the 90s than today’s relationships.  I wonder why our legislative body has become more segregated.

In the afternoon session, Linwood Jones from the North Carolina Hospital Association spoke about recent legislative action.  This legislature was not good to hospitals.  As Linwood described the legislative session this year…”It was all about Medicaid.” (I know you were wondering how the NC Society of Health Care Attorneys annual meeting was going to be germane to Medicaid).  According to Mr. Jones, the Medicaid budget was the primary factor in almost all budget cuts.  And what entities get most of Medicaid funding?

Duh…Hospitals.  Hospitals are the biggest providers in the state, and, in some areas, the biggest employers.

Our Medicaid budget is approximately $13 billion.

Remember…36 million a day is what we spend on Medicaid in NC.

How much of that $13 billion Medicaid budget goes to hospitals?   According to Kaiser Family Foundation, 25.7% for inpatient care.  Or $3.341 billion annually.  Or $9.252 million a day!!

Including outpatient care?  38.7%  Or $5.031 billion annually.  Or $13.932 million a day!!

According to the handy-dandy Wikipedia website, North Carolina has 126 hospitals in 83 counties.  For those of you who never went to 6th grade in North Carolina, we have 100 counties in NC.  (In the 6th grade, if you grew up here, you learn all about North Carolina geography, which apparently didn’t stick, because I still get lost).

That is $13.932 million dollars a day going to 126 hospitals in NC.  That is a lot of money!!!

Does Medicaid matter to hospitals?

Heck, yes!! Remember, a hospital cannot turn anyone away, including Medicaid recipients and uninsured.  Add the fact that the mentally ill in NC are not getting medically necessary services because our managed care organizations (MCOs) have monetary incentives to NOT provide the expensive mental health services; PLUS the fact that Medicaid reimbursements are painfully low, which leads to many physicians not accepting Medicaid, and you get the sad sum of Medicaid recipients ending up in emergency rooms of hospitals.

Don Dalton, a spokesman for the Hospital Association, said that statewide about 46 percent of hospitals’ revenue comes from Medicaid. (See Rose Hoban’s article).

But, hospitals don’t make a huge profit.  Especially on Medicaid recipients.

On average, Medicaid reimburses hospitals 80% of the actual cost for hospital services.

But this year, the General Assembly created a budget in which the 80% will be reduced to 70%.

Medicaid reimbursements were already bad.  But now, the Medicaid reimbursements will be 10% worse.  Subtract 10% from the $13.932 million dollars a day…

This is not a good thing for hospitals nor Medicaid recipients.

When Representative Price was speaking, a woman raised her hand with a question/vignette.  She said that she and her friends had gotten on the health care exchange (Obamacare) (Healthcare.gov) website and “shopped” for health insurance.  She said that all the people who signed up for health care exchange (because it is mandated and there is a penalty for not having insurance) had their premiums increase anywhere from 300%-800%.  Although Rep. Price made a good point, that they all should have contacted Blue Cross Blue Shield (BCBS) and asked why BCBS dropped that particular insurance plan.  Nonetheless, the woman harped on the fact that Obama had promised, “You like your insurance? You can keep it! You like your doctor? You can keep him/her!” (I added the “her.”)

So, here we are…with low Medicaid reimbursements to begin with, high medical costs, and the General Assembly reducing the Medicaid rates for hospitals by 10%.

Incentive to accept Medicaid recipients?  I think not…but hospitals have no choice.

Physicians and other Medicaid providers have the choice as to whether to accept Medicaid patients, but hospitals?  No choice there.  Hospitals must accept Medicaid recipients.  Mandatory!!!

In my opinion, the very first step toward fixing the Medicaid system is RAISING Medicaid reimbursement rates.

Sound counterintuitive? Yes, I agree it sounds counterintuitive.  But think about Medicaid like this:

If you agree with me that Medicaid is an entitlement and that the Medicaid budget is way too high, but that all Medicaid recipients deserve quality health care…if you agree with all that…

And you also agree with me that it is drastically more expensive for Medicaid recipients to go to the emergency room (ER) for health issues that could be solved in a family physicians’ office…if you agree with all that…

Then we would save Medicaid dollars by increasing (drastically) the Medicaid reimbursements.  If doctors had a monetary incentive to accept Medicaid, then more doctors would accept Medicaid (Logic 101).  If more doctors accept Medicaid, then more Medicaid recipients have the ability to go see a doctor.  If more recipients have more office visits then ER visits drop.  If more unnecessary ER visits drop, then the State pays less money to the hospitals, which is an extremely higher rate (even with the 10% reduction) than a higher Medicaid reimbursement to physicians.  Cut the $13.932 million a day to hospitals, not by decreasing the reimbursement rate, but by fewer Medicaid recipient going to the ER…instead have the recipients receive quality care outside the hospital, thus saving money…

Get it?

By reducing the Medicaid reimbursements to hospitals, the legislature did decrease the Medicaid budget, but not in a way that intelligently attempts to fix the system.  The same amount of Medicaid recipients will be going to hospitals.  Since the hospitals cannot turn anyone away, reducing reimbursements to hospitals merely hurts the hospitals.

Want to decrease the Medicaid budget? Increase Medicaid reimbursements (drastically) to Medicaid providers.  More providers accepting Medicaid means more recipients receiving quality care and NOT checking into the ER….

Money saved intelligently.  Too bad the legislature didn’t ask my opinion prior to slashing Medicaid reimbursement rates.

Thomas Mills Writes: Wos Loss

I cannot take credit for this article, but it is important enough to post it.  Thomas Mills wrote as follows:

Well, if the rumors swirling around Raleigh are true, Aldona Wos, Secretary of Health and Human Services is gone. If so, it looks like the McCrory administration waited for a Friday afternoon news dump, hoping people are distracted by the weekend. Regardless, the political establishment will take notice and Pat McCrory, who has stood by the embattled Secretary, will have yet another black eye.

But if the rumors aren’t true, they sure should be. Wos has made a mess of the department. She never understood the role of an administrator. She ran off most of the professional staff and brought in political hacks and ideological soul mates with little or no experience in health, human services or administration.

Instead of taking responsibility for her actions or those of the department, she blamed other people. She avoided the press and at one time said she was opposed to transparency. Several times, Wos tried to alter the truth and when she was caught, never explained or apologized. In her appearance before the legislature, she left members of both parties unsatisfied with her answers.

And it doesn’t help that she comes off as arrogant, condescending and elitist. Not a good combination in politics.

But for all her problems, McCrory stood by Wos. Nobody in either party knows exactly why. Some people think it’s her money. Others say he has an intense personal loyalty. Still other say he’s scared of her.

Who knows. But her biggest sin was hanging her boss out to dry. When salary-gate broke, Wos wouldn’t respond to the press leaving McCrory to defend the indefensible. He lied to cover up her stupid hires, saying that the two campaign hacks beat out more experienced people for jobs when, in reality, nobody else was considered. He should have fired her then, but since he didn’t have the backbone, she should have stepped down. With each of her mistakes, McCrory came out to defend her even as his poll numbers sank.

The whole debacle has been a sorry episode. If she’s done, it’s McCrory’s second cabinet secretary to go in less than a year. We still don’t why Kieran Shanahan left, but there won’t be much question about Wos. She was inexperienced, incompetent, ideological and arrogant. She had no business there in the first place. And that is Pat McCrory’s fault.

Wanted: North Carolina Medicaid Director: Transparent and Open!

With Carol Steckel’s abrupt resignation September 27, 2013, only 8 months after accepting the job as NC Medicaid Director, we North Carolinians were left without a Medicaid Director.  I posted a week or so ago that I can only imagine how difficult it would be to fill the position, considering the absolute mess the Department of Health and Human Services (DHHS) has created recently…the calamity of NCTracks…the negative PR…the high salaries of administration…Who would want to inherit this mess???

While I cannot imagine the person who would actually apply to be our Medicaid Director in the midst of such storms, I do have some advice for whomever attempts to carry the burden of being NC’s Medicaid Director. 

I don’t know why Ms. Steckel left.  I’ve heard numerous hypotheses.  I’ve heard that she didn’t get along with Sect. Wos.  I’ve heard that she left because the NC Medicaid system cannot be fixed.  I’ve heard the bad media press upset her.  I’ve heard she couldn’t handle the scrutiny of the public.

Regardless, anyone who is thinking of applying to be our Medicaid Director needs to understand that this is a public servant job.  This is not a private sector job.  Why is that important?  Because as an officer in the public arena, you are accountable to the taxpayers.  You cannot hide behind rhetoric or stop speaking to media.  As a public servant, you have duty to be transparent to taxpayers.  You will be scrutinized by the public…and this is allowed.

Recently, Secretary Wos responded with this comment when asked about transparency… “I think the word transparency can get pretty dangerous. … If transparency means that we’re in a planning process and you’re asking us, ‘Tell us all the things you’re planning,’ well, my goodness, allow us to work, and then we’ll give you everything that you want.”

While I understand Sect. Wos’ assertion that if all we do is talk then nothing gets done, in the public sector, transparency is, not only desired by taxpayers, but public servants owe a duty to be transparent.  Public servants are not spending their own money.  It’s my money and your money.  We deserve to know how our money is being spent and we deserve to have an opinion as to whether our money is being spent in an economically intelligent fashion.

For example, my blog about the managed care organizations paying the health insurance for its employees and the employees’ families was to point out that our tax dollars are paying for these employees’ families’ health insurance…tax dollars that are meant to provide health insurance to our most needy population.

Similarly, all the media hype about the high salaries of the two 24-year-old staffers, who were given salaries making $85,000 or more, the media are angered because, again, those salaries are paid by us.

Because the money that the Department of Health and Human Services (DHHS) spends is our money, not private funds, transparency is essential. 

A few weeks ago, when I flew to New Mexico, I had to go through airport security.  I had to take off my shoes (yuck! and walk on the airport floor), place my purse and laptop on the conveyor belt and step into the “All-Seeing Machine.”  You know, the machine that you have to place your feet a little apart and raise your hands above your head, while the machine whirls around your body.  I always feel slightly mortified every time I have to go through that machine.  I even suck in my breathe a little so my belly doesn’t poke out.  It is just a strange feeling to have a stranger look that closely at you and scrutinize your body.  You never know what the person looking at your image is thinking.  Being scrutinized is not fun.

Similarly, as NC Medicaid Director, and a public servant, you will be scrutinized.  Every word.  Every action…and non-action.

Remember Mary Poppins?  Remember the sweet, little song the two children sang about the criteria for their new nanny?

If you want this choice position
Have a cheery disposition
Rosy cheeks, no warts!
Play games, all sort

You must be kind, you must be witty
Very sweet and fairly pretty
Take us on outings, give us treats
Sing songs, bring sweets

Never be cross or cruel
Never give us castor oil or gruel
Love us as a son and daughter
And never smell of barley water…

Well it applies to the Medicaid Director position too.  Here is the “Perfect NC Medicaid Director Song:”

If you want this choice position
Have an open disposition
Know Medicaid laws and rules
Don’t treat media as fools
 
You must be strong, you must be smart
Very tenacious, open heart
Take on naysayers, show guts
Move our Agency out of ruts
 
Be transparent, don’t circumvent
Never say to media, “No comment.” 
Love our citizens; our state
And always, always update…

I found the job posting for our Medicaid Director on the National Association of Medicaid Directors’ (NAMD) website.

Here it is:

DIRECTOR OF MEDICAL ASSISTANCE

The North Carolina Department of Health and Human Services (DHHS), in collaboration with our partners, protects the health and safety of all North Carolinians and provides essential human services.

Within DHHS, the Division of Medical Assistance (DMA) provides access to high quality, medically necessary health care for eligible North Carolina residents through cost-effective purchasing of health care services and products. The Department of Health and Human Services and DMA are devoted to quality customer service.

The Director of Medicaid directs the administration of the state’s Medicaid and NC Health Choice Programs. The Medicaid program serves more that 1.7 million North Carolinians and provides services to children, the elderly, the blind, the disabled and those eligible to receive federally funded assisted income maintenance payments. The North Carolina Health Choice (NCHC) Health Insurance Program for Children is a comprehensive health coverage program for low-income children. The goal of NCHC is to reduce the number of uninsured children in the State. The program focus is on families who make too much income to qualify for Medicaid but not enough to afford private or employer-sponsored health insurance.

DMA has approximately 400 employees and a budget impact of 14 billion dollars which includes 3.8 billion in state appropriations. DMA partners with over 78,000 physician providers throughout the state to provide essential services to recipients. The Director is responsible for multi-million dollar contracts and performs an array of fiscal agent and administrative services which include cost reimbursement and integrated payment management reporting to local management entities (area mental health programs). The position manages the state waiver program and demonstration projects. The Director is the primary interface with the Federal Centers for Medicare and Medicaid Services (CMS) and for the Committee Management Office. (CMO)

KNOWLEDGE, SKILLS AND ABILITIES:

Prior leadership and policy role in large complex organization administering the Medicaid Program or within a Medicaid Reimbursement or Health Insurance Agency
Demonstrated knowledge of the federal and state funding process for Medicaid and Medicare
Proven ability to build consensus among diverse stake holders which includes constituents, providers, advocacy groups, the media, the public and the legislature
Demonstrated ability to provide leadership during a time of change or reorganization

MINIMUM EDUCATION AND EXPERIENCE REQUIREMENTS:

A Masters Degree in Business, Public Health, Health Administration, Social or Clinical Science or a related field and six years of broad management experience in Health Administration or in Healthcare financial management of which at least three years must be at the Director or Assistant Director level of a statewide or federal division in Health Administration or Financial Management.

To be considered for this opportunity please submit a detailed resume to alma.troutman@dhhs.nc.gov

To learn more about the North Carolina Department of Health and Human Services, please visit our web site at: www.ncdhhs.gov

All applications will remain confidential.
Equal Opportunity Employer

Nowhere in the advertisement for the NC Medicaid Director does it say what the Medicaid Director ACTUALLY has to do in real life.

Undergo scrutiny.  Talk to the public.  Maintain transparency. Be a public figure in a time of crisis.

It’s our money.  So talk to us.

Government Shutdown: No Medicaid Funds Available in D.C., So Why Am I Still Getting My Mail!

Hey, have you heard??? Our federal government has shut down. So why am I still getting mail???

Unless you have lived under a rock for the past couple weeks, you are aware that our esteemed federal government has shut down.  At least…partially.  I keep getting mail.  Social security is still getting paid.  But don’t you dare try to visit a national monument…those are off-limits!! Really? Who decided what gets shut down and what stays open?  How is it that I still get my cable bill, but cannot visit Yellowstone National Park??

How is all this tomfoolery affecting Medicaid?  Minimally, in most areas, but Medicaid fundings HAS STOPPED in Washington D.C.

Why stop Medicaid funding in D.C. when the federal air traffic controllers are still working.  The State Department continues processing foreign applications for visas and U.S. applications for passports.  The federal courts are open.  The National Weather Service is still working.  Student loans are still getting paid. The Veterans’ hospitals are all up and running.  The military is still working.  I guess, Obama and White House staff are still working. (Although Obama could be on the golf course).  The Post Office is delivering mail.

Yet, here are some random federal actions and agencies that are actually stopped/closed:  Food safety inspections are suspended; U.S. food inspections abroad have also been stopped.  Auto recalls and investigations of safety defects are stopped.  Taxpayers, who filed for an extension in the spring, still have to pay their taxes by today, yet the IRS is not processing tax returns (How does this make sense??). The Consumer Product Safety Commission (CSPC) is not working.  (Great, after the CPSC starts working again, there are sure to be numerous lawsuits based on new product defects that have been placed in the market over the last 2 weeks).  The Environmental Protection Agency (EPA) has ceased to run, which means we have two weeks of allowable pollution.  Many at the Federal Bureau of Investigations (FBI) and the federal housing agency are furloughed.

How does this shutdown make any sense?? Who determined that the IRS should not process tax returns, but should accept taxes?  Who decided that safety inspections should be stopped, but passports should still be processed?

That safety inspections of food and products should halt, but students should still get federal loans.

Where is the logic?

It is as if someone said, “Shutdown the federal government!! Except not the mail, passports, and the weather service…keep those running!”

And then Medicaid in D.C…. Why did Medicaid funding stop only in D.C.??  While I still think if the mail is being delivered that D.C. providers could get Medicaid fundings, I will attempt to explain the illogical reason below:

Because D.C. is not a state.  D.C. is a local government without a state, so its budget must be authorized by U.S. Congress.  And Congress has not passed a budget.

D.C. has $2.7 billion budgeted for Medicaid, but providers are getting nothing (and, quite possibly, some recipients).  I can only imagine how this is negatively impacting health care providers in D.C. I am sure many of the providers are still rendering services unpaid.  But some, I would imagine, are closing up shop.  I know I could not last financially without a paycheck for 3 months.  I am sure many of the D.C. providers are no different.

But it still makes no sense.  Just like NC, D.C. pays for about 30% of Medicaid with the federal government reimbursing about 70%.  If NC’s federal reimbursements are still being paid, why not in D.C.?

And why am I still getting mail????

Well, my heart goes out to all the Medicaid providers and Medicaid recipients in D.C.  I hope you receive Medicaid fundings very soon.

Although, at least D.C. providers know that, at some point, the Medicaid funds will be funded; whereas in NC we still have NCTracks.

Attention: All Medicaid Providers Whose Services Require Prior Authorization: A Way to Increase Revenue and Help Medicaid Recipients…Or…Killing Two Birds with One Stone

Attention: All Medicaid Providers Whose Services Require Prior Authorization

A Way to Increase Revenue and Help Medicaid Recipients

Have you heard the cliché: “Killing two birds with one stone….?”

The phrase is thought to have originated in the early 1600s when slingshots were primarily used for bird hunting.  (BTW: My husband, who is an expert bird hunter (with guns), I am sure, would be able to hit two birds with one stone…he is that good.  In fact, he may have already shot two birds with one bullet).  Anyway, Thomas Hobbs, an English political philosopher, is generally given credit for coining the phrase in 1656, although Ovid has a similar expression in Latin over 2000 years prior.  Killing two birds with one stone generally means achieving two objectives with one action. (Which, obviously, is a good thing).

For our purposes here, killing two birds with one stone means that by undergoing one action (appealing all Medicaid recipients’ denials, terminations, and reductions for services requiring prior authorization) two positive results are achieved:

1. The Medicaid recipients have their denials, terminations, and reductions appealed (or…people who need services may actually get those necessary services); and

2. Your provider company makes more money.

Not all Medicaid services require prior authorization.  But many do.  Many prescription drugs require prior approval.  Certain services during a pregnancy for a Medicaid pregnant woman require prior authorization. In behavioral health care, almost all services require prior authorizations (although there are some unmanaged visits in outpatient behavioral health (OBT) that do not require prior authorization).  Even though other Medicaid services require prior authorization, this blog and NCGS 108D only applies to behavioral health care (because NCGS 108D applies to MCOs and the MCOs only manage behavioral health care).  You should appeal all other denied, terminated, or reduced Medicaid services that require prior authorization, but the appeal process in this blog pertains to behavioral health care.

Why care about Medicaid recipient appeals?

It is indisputable that people start companies to make money (except 501(c) companies).  You’ve heard all the cliches…”Money makes the world go around…” “The lack of money is the root of all evil…” “Money: power at its most liquid…”

We’ve also heard all the cliches…”Money can’t buy happiness…” “I have no money, no resources, no hope. I am the happiest man alive….” “Money has never made man happy, nor will it, there is nothing in its nature to produce happiness. The more of it one has the more one wants.”

Regardless whether you believe that money is a necessary evil or the key to happiness, it is without question that people need money to get by in life.  Therefore, when people create companies, it is, normally, with the intent to make money.

Medicaid providers are no exception.

True, Medicaid reimbursements are crappy.  But, despite the crappy/low Medicaid reimbursements, Medicaid providers still hope to make some profit…and do good. (2 birds…1 stone).

We all want to make money and help Medicaid recipients, right? (I know I do).

So with my “handy dandy” tips in this blog, you, too, can kill two birds with stone. You can do both: make more money and help Medicaid recipients.

Wait, I thought providers could not appeal on behalf of our clients? I have heard this incorrect statement over and over from multiple clients.  It simply is not true.

NCGS 108D(4)(b) states that “[e]nrollees, or network providers authorized in writing to act on behalf of enrollees, may file requests for grievances and LME/MCO level appeals orally or in writing. However, unless the enrollee or network provider requests an expedited appeal, the oral filing must be followed by a written, signed grievance or appeal.” (emphasis added).

You just need the Medicaid recipient’s consent in writing.

Increased Profit AND Providing Medicaid Services to Recipients: Two Birds…One Stone!

First, how would appealing all terminations, denials and reductions for Medicaid services increase profit for you, as a provider?

For terminations and reductions (not initial authorizations), if you appeal, the Medicaid recipients are required to receive maintenance of service (MOS).  This means that, at the very least (even if you lose), if you appeal, you are able to provide services and be reimbursed for services during the appeal process. 

For example, you have a developmentally disabled (DD) Medicaid client, who has received 8 hours/day personal care services (PCS) for the last 4 years.  You submit your yearly plan of care (POC) requesting 8 hours PCS/day per norm.  The managed care organization (MCO) reduces your client’s PCS to 6 hours/day.  If you timely appeal the reduction or termination, the MCO will be required to reimburse for 8 hours PCS/day throughout the appeal process.

NCGS 108D-6(c) states: “Continuation of Benefits. – An LME/MCO shall continue the enrollee’s benefits during the pendency of a LME/MCO level appeal to the same extent required under 42 C.F.R. § 438.420.”

42 C.F.R. 438.420 states that:

“Continuation of benefits. The MCO or PIHP must continue the enrollee’s benefits if—

(1) The enrollee or the provider files the appeal timely;
(2) The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;
(3) The services were ordered by an authorized provider;
(4) The original period covered by the original authorization has not expired; and
(5) The enrollee requests extension of benefits.

Pay particular attention to subsection (5)…the enrollee must request MOS.  Don’t forget to add that little phrase into the form that you have the enrollee sign to consent to appeal.

MOS allows you to be paid during the appeal AND the Medicaid recipient to receive the medically necessary services during the pendency of the appeal.

Two birds…one stone.

For terminations and reductions, there is no need to ask for an expedited hearing (will discuss momentarily), because with MOS, there is no hurry (the recipient is receiving the needed services and you are getting paid).

So, let’s turn to an initial denial for a Medicaid service that requires prior authorization and the appeal process:

If the MCO denies an initial authorization, the Medicaid recipient is not entitled to MOS.  However, appealing these initial denials are just as important to (a) the recipients; and (b) your profit as appealing the terminations and denials.

But an appeal can takes months and the recipient (assuming medical necessity truly exists) needs the behavioral health care services in order to not decompensate. So how can the appeal help?

Answer: Request an expedited appeal.

NCGS 108D-7 states:

“When the time limits for completing a standard appeal could seriously jeopardize the enrollee’s life or health or ability to attain, maintain, or regain maximum function, an enrollee, or a network provider authorized in writing to act on behalf of an enrollee, has the right to file a request for an expedited appeal of a managed care action no later than 30 days after the mailing date of the notice of managed care action. For expedited appeal requests made by enrollees, the LME/MCO shall determine if the enrollee qualifies for an expedited appeal. For expedited appeal requests made by network providers on behalf of enrollees, the LME/MCO shall presume an expedited appeal is necessary.”

Important: You still have 30 days to appeal.

Even more important: The MCO is required, by statute, to PRESUME an expedited appeal is necessary.

True the General Assembly really gave mentally ill, developmentally disabled, and substance abuse population the shaft when they passed, and McCrory signed, Senate Bill 553, now Session Law 2013-397, by placing the legal burden of proof on the Medicaid recipient in all circumstances (really??), but the small ray of hope is that, at least as it pertains to expedited appeals, the MCO must presume that an expedited appeal is necessary for the well-being of the recipient.

Going back to expedited appeals, the MCO must make “reasonable efforts” (yes, there is too much wiggle room there) to notify the Medicaid recipient/provider of a denial of an expedited appeal within 2 days.  I also believe that is in the best interest of an MCO to authorize expedited appeals, because….could you imagine the implications and legal liability on the MCO if the MCO denies an appeal to be expedited and something horrible happens to the Medicaid recipient as a direct result of the MCO’s refusal to expedite the appeal????  Or, even worse, the recipient harms others as a  result of the appeal not being expedited??? WHOOO HOOOO….talk about bad PR!!!

So, two days to determine whether the MCO will accept the request for an expedited appeal.  How long for a decision?

According to NCGS 108D-7(d), “[i]f the LME/MCO grants a request for an expedited LME/MCO level appeal, the LME/MCO shall resolve the appeal as expeditiously as the enrollee’s health condition requires, and no later than three working days after receiving the request for an expedited appeal. The LME/MCO shall provide the enrollee and all other affected parties with a written notice of resolution by United States mail within this three-day period.”  (emphasis added).

So, basically, if the MCO takes 2 days to decide to accept the expedited appeal, then there is only 1 additional day to determine the results of the appeal.  That is fast…I don’t care who you are!!

If the MCO denies the expedited appeal, then the MCO has 45 days to provide a decision.

Very Important:  Any adverse decision from an MCO is appealable to the Office of Administrative Hearings (OAH).

Ok, recap:  You, as a provider, want to appeal all Medicaid recipient denials, terminations, and reductions for the following two reasons:

1. Increase profitability for your company; and

2. Help the Medicaid recipients by appealing denials, terminations or reductions, and, hopefully, obtaining the medically necessary services for your clients.

Win…win.

2 birds…1 stone.

NC State Auditor, Beth Wood, Calls Out Inaccuracies Stated at the NC Oversight Committee Regarding NCTracks

After the October 8, 2013, Oversight Committee meeting regarding NCTracks, our State Auditor, Beth Wood, had some clarifying remarks.  By clarifying, I mean, Wood points out the (we don’t want to use such a harsh words as “lies”) inadvertent mistruths that came to light at the October 8, 2013, Oversight Committee meeting.  (Click the blue phrase to see a portion of the video of the actual meeting).

One inadvertent mistruth was as follows:

During the Oversight Committee, Senator Parmon asked Secretary Wos whether any professional opinion had been given to the Department of Health and Human Service (DHHS) warning DHHS that NCTracks was not ready to go live July 1, 2013.

Secretary Wos answered: “No, Senator.”

Was the State Auditor’s May 2013 Performance Audit explicitly stating that NCTracks was not ready to go live not enough???? Or maybe Secretary Wos did not consider the Performance Audit a “professional opinion.”  She may have a point.  Perhaps the Performance Audit should be considered “professional fact.”

It is important to remember that this $484 million contract (which price tag has been surpassed) is funded by our tax dollars.

Here is Beth Wood’s response to the Oversight Committee:

October 10, 2013

Honorable Justin Burr
NC House of Representatives
300 N. Salisbury Street, Room 307A
Raleigh, NC 27603-5925

Dear Representative Burr,

The Office of the State Auditor has several concerns about incomplete information provided to the Joint Legislative Oversight Committee on Health and Human Services during its committee meeting on October 8, 2013. We would like to clarify some of the information provided to the committee by officials from the Department of Health and Human Services.

1. When Senator Parmon asked Secretary Wos whether the Department of Health and Human Services had received any professional opinions indicating that that the NC Tracks system may not be ready to go-live on July 1, the Secretary responded “No, Senator.” This answer ignores the work of our audit issued on May 22, 2013, titled: “NCTracks (MMIS Replacement) – Implementation.” The State Auditor met and presented Secretary Wos with the findings and recommendations as early as March 27, 2013, to allow her department to begin addressing problems uncovered in the audit.

The audit findings from our report included that:

  •  Independent assessments regarding system readiness and testing were flawed and put system readiness at risk
  • Access control and security environment were at risk on go-live
  • No formal criteria framework existed to determine if NCTracks was ready for go-live

“The Department should re-evaluate its current “Go” decision for July 1, 2013, once final Go/No-go criteria is established and documented,” our audit recommended. “This assessment should incorporate the final user acceptance testing and production simulation testing results.”

2. In his presentation, Mr. Cooper referenced NCTracks testing procedures done by DHHS and its vendor, CSC, prior to the July 1 go-live date and indicated that the system had met their benchmarks. Our audit, however, found several shortcomings in the testing of the system.

Our findings indicated that:

  • Out of 834 “critical” priority test cases affecting various Medicaid and provider business processes, 123 critical tests had failed and 285 critical test cases were not performed. The department itself defined which business processes were critical, and according to the department, “critical” test cases were absolutely required to be tested.
  • Our audit stated, “If user acceptance testing is accepted without addressing these issues, a high risk exists that critical NCTracks functions could have major errors on go-live and possibly lead to a delayed CMS certification of the system.”
  • Oversight over the production simulation testing process was inadequate. Our work found that the department allowed CSC to develop the acceptance criteria for its own work, one week prior to the end of the testing phase, and that the department lacked clear test benchmarks.

3. Mr. Cooper stated during this presentation that, “On February 28th we [DHHS] reached a point-of-no-return when the state had to cancel the HP contract.” This contradicts what Department leaders told state auditors during our NCTracks pre-implementation audit. During our audit, DHHS senior leadership repeatedly indicated that the termination of the contract with HP, the vendor for the Medicaid system that was replaced by NCTracks, should not be considered final acceptance of the project.

“According to the Department, the letter to HP does not constitute formal acceptance of the NCTracks system,” our audit states. “The Department has indicated that if the NCTracks system is not ready for go-live on July 1, 2013, HP will be willing to continue its services as long as needed. However, there is no guarantee that this continuation of services would occur or at what cost to the State as this is not in writing.”

The fact that Mr. Cooper and the Department now characterize the contract termination as a “point-of-no-return” indicates that the Department’s decision to go-live did not take into account the actual readiness of the system or the critical risks that were raised between February 28 and June 30.

Our full audit report on NCTracks can be viewed at http://www.ncauditor.net/EPSWeb/Reports/InfoSystems/ISA-2013-4410.pdf.

Our staff is available to answer any questions or concerns you may have about our work. If you wish to discuss this information with me, you can contact me at 919-807-7628.

Thank you for your work on behalf of the people of North Carolina.

Sincerely,

Beth A. Wood, CPA
North Carolina State Auditor