CCME’s Medicaid Audit Bloopers: Ring Around the Rosie, We All Fall Down

“Ring Around the Rosie.” What a fantastic children’s rhyme; it brings back nostalgic memories of my daughter being young. We would sing “Ring Around the Rosie,” while holding hands and running in a circle, and then fall as hard as possible (without hurting ourselves) onto the ground. We would just flop on the ground and my daughter loved it.

Although many people believe that the rhyme describes the time during the Great Plague in England in 1665, which is pretty morbid, it is still a fun children’s game.

But other than “Ring Around the Rosie,” it is no fun to run in circles until you get dizzy and fall to the ground. People usually just don’t spin around and around for fun.

Sometimes going through a Medicaid or Medicare audit can feel like you are running around and around in circles and getting ready to fall. So too, can you feel this way if you are undergoing a prepayment review with the Carolinas Center for Medical Excellence (CCME).

First, what is prepayment review?

N.C. Gen. Stat. 108C-7 allows for prepayment review. See also my blog, “NC Medicaid: CCME’s Comedy of Errors of Prepayment Review.” Or “CCME’s Prepayment Reviews Violate NCGS 108C-7!! Seriously!!

Prepayment review means that a contracted entity, in this case CCME, reviews your claims BEFORE you get paid for services rendered. While on prepayment review, you do not receive Medicaid reimbursements. This can continue for 12 months or unless you reach 70% accuracy for three consecutive months.

70% doesn’t sound too hard, right? But, what if the auditing entity runs you in circles, gets you dizzy and makes you fall to the floor?

Here’s the story:

A client of mine owns a home health care company. She and her staff provide personal care services (PCS) to those who are eligible. For those who do not know what PCS is, it is basic caregiving services to help people with activities of daily living (ADLs), such as toileting, dressing, and eating.

My client, we will call her Provider Nancy, was undergoing a prepayment review that had been conducted by The Carolinas Center for Medical Excellence (CCME).

We won’t even talk about the fact that by the time Nancy came to me she had been on prepayment review for 17 months, but that the statute, NCGS 108C-7, only allows a provider to be on prepayment review for 12 months.

When she was undergoing prepayment review, CCME gave her low accuracy rates for a number of reasons, some of which were so absurd, you will laugh out loud.

For example, CCME denied claims because the service notes did not denote that the in-home aid put shoes on two of her clients. There were multiple dates of service (DOS) so these two clients contributed heavily to her low accuracy rating. I asked Nancy why the service note did not denote that her staff put shoes on her clients. She told me that these clients are double amputees. They do not have feet. So Nancy was dinged in her audit for not putting on shoes on someone without feet.

Nancy’s story also highlights the confusion at CCME about its own prior authorization records for PCS. CCME repeatedly demanded a copy of the authorization for Nancy to provide PCS. If a provider like Nancy did not have a prior authorization, she would never have received payment in the first place.  Nonetheless, CCME told Nancy to that she had not documented the prior authorizations. Oddly enough, in order to produce the authorizations she had obtained, Nancy had to contact CCME, because at the time of her prepayment review audit, CCME was the entity that reviewed independent assessments to determine prior authorization.  CCME was saying she had no prior authorization, but it was CCME who gave her the prior authorization!!  How can a system operate like this, when an important reviewing entity does not know what is in its own records?

It got worse: Nancy would then ask CCME for CCME’s prior authorization letter,  but CCME could not or would not give her a copy.  Then CCME reps attended the hearing and stated that Nancy was dinged for not having a prior authorization. Can a system get any more backward??

Ring around the rosie…

Sometimes Nancy’s service notes showed that her in-home aids did extra chores for her clients. Maybe an in-home aide would help a client ambulate because the client had sore muscles that particular day, but, according to the plan of care (POC), the client did not need hands-on assistance to ambulate. CCME would ding Nancy for the service note not being in compliance with the POC. Nancy was getting dinged in the prepayment review for doing MORE GOOD for her clients than what was required. It was not as if Nancy’s in-home aides were foregoing aid to the ADLs on the POC. Oh, no! The in-home aid was going over and above the call of duty for a client. And Nancy would get dinged.

We all fall down!

Needless to say, Nancy did not meet the 70% for three consecutive months in order to be removed from prepayment review. But, remember, Nancy was not paid for 17 months; she came to me 17 months into the prepayment review. She was hurting financially.

Now, because of CCME’s confusing and inaccurate review, Nancy had little money and now had to hire a lawyer. Sure, we got her off prepayment review and got her paid, but she had to shell out thousands of dollars for attorneys’ fees.

If you have to undergo “Ring Around the Rosie” during a prepayment review, I think that the auditing entity, in this case CCME, should have to pay for attorneys’ fees. Give some sort of disincentive for the auditing companies to be sloppy. A penalty.

Now Liberty Mutual, not CCME, authorizes PCS.. But CCME continues to conduct prepayment reviews.

Ring around the rosie
Pocket full of posies
Ashes, ashes
We all fall down!

About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on May 8, 2014, in Administrative Law Judge, Administrative Remedies, Carolinas Center for Medical Excellence, CCME, Division of Medical Assistance, Health Care Providers and Services, Home Health Aide Services, Home Health Services, In Home Care Services, Lawsuit, Legal Analysis, Legal Remedies for Medicaid Providers, Medicaid, Medicaid Appeals, Medicaid Audits, Medicaid Billing, Medicaid Providers, Medicaid Reimbursements, Medicaid Services, Medicare and Medicaid Provider Audits, NC, NC DHHS, NCGS 108C-7, North Carolina, Office of Administrative Hearings, Personal Care Services, Petitions for Contested Cases, Plan of Care, Prepayment Review, Prior Authorization, Regulatory Audits, Service Notes and tagged , , , , , , , , , , , , , , , , , , , , . Bookmark the permalink. 3 Comments.

  1. Diane Sherrill

    my name is Diane Sherrill, I am going though the same thing that Nancy was going though can you take my case. My company is RESTORATION HOME CARE SERVICES my e-mail is I NEED HELP

    On Thu, May 8, 2014 at 1:43 PM, medicaidlaw-nc

  2. Linda Francis

    Wow. That’s just sick. Is there no other recourse? Political pressure? Class action?

    Thank you for the invitation to retain your firm to help with the problem with the Blue Cross Blue Shield Blue Value plan edging out willing providers. I will give that some serious thought.

    I didn’t want to post this next bit, It but I did want to share some information you may or may not find interesting re: Medicaid and Medicare incentives for early adoption of electronic health records.

    The Center for Medicaid services offered financial incentives for physicians to adopt electronic health record systems earlier then when they would be required of everyone serving Medicaid or Medicare patients. For Medicaid providers the amount of reimbursement for five years was to be $64,000. For Medicare, something like 42,000 or thereabouts.

    I bought my system in 2010. The attestation process was so complicated that I could not get it done in 2011, so I hired an assistant to help me with it, and in 2012 I made my first attestation and received an initial payment of approximately $21,000. To qualify for the first years reimbursement I only needed to show that at least 30% of my patients were Medicaid enrollees and that I had adopted a CMS approved electronic health record system.

    For year two, I had to show that I had accomplished something called “meaningful use”. The complexity of the process delayed my attestation again. The deadline for submitting information for program year 2013 was April 30, 2014. After all the effort my staff put into getting the application done, I was horrified to realize that I would not qualify for the second years incentive because I had failed to meet 2 of the 10 required “core” criteria. The first was to record race, ethnicity, and language preference for the majority of my patients.

    Mind you, it’s not that I did not have these demographic items in my notes about my patients. It’s just that I had not recorded it into the EHR in such a way that I could produce a structured database. I could have had my assistant review approximately 630 progress notes. But it turned out I had missed a second criterion which entirely disqualified me.

    The requirement was to offer a written clinical summary to each patient after each visit. I had to show I had done that for a certain percentage of my patients, and in a way that would give me an exact count and stand up to a postpayment audit. Now, I don’t really know that many doctors who do this. I can almost understand asking an internist or family practice doctor to do this. But a psychiatrist? We talk to people. We do therapy as well as medication management. We don’t routinely give a piece of paper with all their personal psychiatric data for them to carry out and keep in a folder… or lose, or leave lying around.

    Unfortunately, because I did not realize these deficits until last month, the same problem persisted in 2013 and so i will not be qualified for the third year of incentive payments. So, I’m out $8500 x 2=$17,000.

    Incidentally, CMS changed the rules after the first year of the program and reduced the portion of the incentive payment payable in years two and yhree by several thousand dollars. Perhaps to discourage physicians from dropping out. That’s just my guess.

    I stopped accepting Medicaid or Medicare in November 2013, so participation in years four and five are not an option for me anyway. It did pay for my medical record system entirely in the first year. and so that’s a good thing. I hate not being able to collect the rest of the incentive money, but I figure I have saved myself over $17,000 worth of headaches over the next several years by jumping the CMS ship.

    BTW as I am sure you have already surmised, these Medicaid audits will be a lot easier for the auditors now that they have access to everything in electronic databases. Spend less, recoup more. Too bad the government can’t apply this skill set to balance the budget. 🙂



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