Category Archives: Eligibilty

Knicole Emanuel Speaks Out on WRAL: You Do Not Pee in a Cup at the Dentist!

WRAL Knicole

http://www.wral.com/dentists-left-holding-bills-for-services-to-pregnant-women/15311392/

Or click here.

“A Modest Proposal for the ACA Employer Mandate”

We all know about the ACA employer mandate. It placed a tremendous burden on employers, many of whom will only feel this burden weighing them down as we ring in the new year because, starting in 2016, companies with over 50 employees must offer health insurance to full time employees (those who work over 30 hours per week).

So how much does it cost you, as an employer, to hire an employee? Are there exceptions? Are there loopholes?

We will get to the first question in a second. The answer to the last two questions is a “yes,” which will be discussed further in this blog.

Cost of an employee

Employers have to pay Social Security tax, Medicare tax, state unemployment insurance, and, now in 2016, health care insurance benefits (if the company has 50+ employees).

Social Security tax is 6.2%. Medicare tax is 1.45%. State unemployment tax differs from state to state, but it can range from 0% to 12.27% (Massachusetts). For the sake of clarity, we will use 5%.

Health insurance benefits also can vary greatly depending on the plan. According to the Kaiser Family Foundation/Health Research & Education Trust 2015 Employer Health Benefits Survey, annual premiums for employer-sponsored family health coverage reached $17,545 this year, up 4 percent from last year, with workers on average paying $4,955 towards the cost of their coverage.

This means that the employer, on average, is paying $12,490 per year per employee for health care benefits.

Assuming a base salary of $70,000, an employer would spend:

Social Security tax: $4,340

Medicare tax: $1,015

State unemployment tax: $350

Health care insurance benefits: $12,490

For a whopping total of $18,195 per year.

Think about this…if you offer your employee a salary of $70,000/year, he/she has to produce revenue for that company of, at least, $88,195 per year in order for you to break even. As you well know, successful companies are not in the business of breaking even, so you will expect your employee to create, at least, over $90,000 of profit in order to be paid a salary of $70,000.

None of the above contemplate a 401K plan. If you’re in a position to offer your employees a 401K plan, they will need to be that much more profitable.

So how can you, as the employer of a home health company, a long term care facility, a dentist practice, or other health care provider decrease the amount of money spent on health care benefits?

“A Modest Proposal for the ACA Employer Mandate”

Before we begin our journey of “A Modest Proposal for the ACA Employer Mandate,” I would like to give a bit of an English lesson on satire, lest one of you miss it. Satire is defined as, “the use of humor, irony, exaggeration, or ridicule to expose and criticize people’s stupidity or vices, particularly in the context of contemporary politics and other topical issues.” It is burlesque. And so I write this blog in the vein of Jonathon Swift’s “A Modest Proposal” (for those of you who have not heard of it, I suggest you click on the link above). For the faint of heart, those easily offended, or those too lazy to click on the link, I suggest not reading further.

Below is my “A Modest Proposal for the ACA Employer Mandate.”

  1. Hire childless singles.

Childless singles are cheaper to insure. So screen your potential employees. Ask whether they intend to have children and warn them that you operate a non-child company. Explain that if you discover that any employee has a dependent child it will result in immediate termination. Bonuses for those who undergo voluntary hysterectomies or vasectomies.

2. Hire old people.

People over 65 are eligible for Medicare. They’re loyal; they don’t talk back. The only things they complain about are their ailments. Many expect little pay because they, or their parents, went through the Great Depression. You can be sure that they will not spend their time on Facebook, Twitter, Instagram, or other social media because they don’t know how. If the position involves driving, you can sure they will get no speeding tickets. Best of all, you know that you are not undertaking a long-term commitment.

3. Hire poor people.

People below the poverty line are eligible for Medicaid. They rarely talk on the phone to friends. Many even only talk to themselves, which is fantastic (and not creepy at all) in the workplace. They are never late with excuses of bad traffic; and their homes are, most likely, going to be very near by (and maybe right out front). They never try to “one-up” the Joneses’. You will never see them bragging about their new Iphones, Louis Vuitton bag, or Mercedes Benz.

5. Hire lazy people.

People who work under 30 hours per week do not get offered health care coverage. Hire employees who enjoy video games too excess. All the better if they own Assassin’s Creed: Victory, Battlefield: Hardline, and Dying Light. It’s an office party every day – no need to worry about them working over 30 hours per week – they like vodka, bourbon, and gin. It’s even better if they enjoy the occasional (daily) marijuana. Embrace a drug-friendly environment.

If you follow the above hiring tips, you too can avoid paying the ACA employer mandate. Remember, the key to success is to only hire childless singles, and old, poor, and lazy people.

And you’ve struck gold if you hire a childless, old, lazy, poor, single person….Goldmine!

Broken Promises Could Promise Disaster for Pediatricians! or “I Don’t Give a Damn” What the Law Is!

In 2013 and 2014, those of you who are primary health care physicians received a boost in Medicaid reimbursement rates up to the Medicare rates for E&M and vaccine administration CPT codes. Many of you self-attested to being primary care physicians. In other words, you determined that you act as a primary care physician. No official acting on behalf of the government reviewed your self-attestation and approved or denied your self-attestation.

What if the government decides, retroactively, that you did not qualify as a primary care physician and attempt to recoup the enhanced payments?? Is that allowed? “A retroactive take back?”

We all know that retroactive take backs occur in other types of audits!

This whole situation reminds me of my favorite movie of all time: Gone With the Wind…you know, Scarlett O’Hare, Rhett Butler, the Civil War…Over Thanksgiving, AMC had a Gone With the Wind marathon, and I must have watched it 4 times (I was sick, so I couldn’t do much else).

The plot is that Rhett is in love with Scarlett the entire movie, which spans over a fictious, “movie time” of two decades. And Scarlett is not in love with Rhett the entire movie until the very end.Once she finally realizes her love for Rhett, he is beyond frustrated and wants nothing to do with her.

She asks, “Rhett, oh, Rhett, what am I supposed to do?” To which he responds, “Frankly, my dear, I don’t give a damn!”

There are many themes found in Gone With the Wind, but the one most appropos is “You may think you understand reality, but, in the end, your reality may be a fictitious dream.”

Similarly, in 2013 and 2014, if you are a primary health care physician, you received a boost in Medicaid reimbursement rates up to the Medicare rates for E&M and vaccine administration CPT codes. You believed the rate hike to be reality.

This rate hike was a big deal for physicians, especially pediatricians. Pediatric practices rely heavily on Medicaid, usually from 20-100%. This rate hike took a reimbursement rate of approximately 78% of the Medicare rate, which, by the way, has been frozen by our legislature at the 2002 rate, plus an additional 3% reduction, followed by another 1% reduction to 100% of the Medicare rate. Quite an increase!

Well, that so blissful increase in Medicaid rates may come back to bite you!!! You thought that you were receiving higher Medicaid reimbursement rates, but, in the end, may you have to pay it back?

The reality of receiving higher Medicaid reimbursement rates may truly only have been a fictitious dream.

“Why,” you demand. “Why?” “Well,” says the government, “I don’t give a damn what the law is.”

Caveat lector: It is not 100% certain that you will be audited. This blog is only a warning as to a possibility. If, in fact, you are audited, then you have legal rights!

Let’s go over why there may be audits for those of you who self-attested to being primary care physicians…

In order to receive this increased rate hike, physicians had to self-attest that he/she :

  1. “Is Board certified as family medicine, general internal medicine, or pediatric medicine; and/or
  2. Has furnished evaluation and management services under codes described in paragraph (b) of this section that equal at least 60 percent of the Medicaid codes he or she has billed during the most recently completed CY or, for newly eligible physicians, the prior month.”

If you are Board certified in family medicine, general internal medicine, or pediatric medicine, there should not be a problem. There isn’t anything to argue. You are either Board certified or not.

However, if you are not Board certified, you will be relying on the government’s auditors to determine whether your practice comprises 60% of applicable Medicaid codes during the most recent calendar year.

Hmmmmmm…

Then, if the government’s auditors determine that your practice comprises of only 57% of applicable Medicaid codes, you may be charged with returning all the money you received as enhanced payments during 2013 and 2014.

And we all know how accurate some of our government’s auditors are…

So there you were, a physician, happy to self-attest to being a primary care provider, happy to receive higher reimbursements for two years, and with no thought of recoupments.

Then…BOOM…you are hit with the realization that you may be liable to the government for a recoupment of those enhanced reimbursements.

Because, frankly, my Dear, the government does not give a damn. Your reality was, in fact, a mere fictitious dream.

NCTracks, MPW, and Eligibility: The Three Billy Goats Gruff

The story of The Three Billy Goats Gruff tells a tale of 3 billy goats, one puny, one small, and one HUGE. The first two billy goats (the puny and small) independently try to cross the bridge to a green pasture. They are blocked by a mean troll, who wants to eat the billy goats. Both billy goats tell the troll that a bigger billy-goat is coming that would satisfy the troll’s hunger more than the puny and small goats. The troll waits for the HUGE billy-goat, which easily attacks the troll to his death.

The moral: “Don’t be greedy.”

My moral: “You don’t always have to be HUGE, the puny and small are equally as smart.” – (They didn’t even have to fight).

The majority of Medicaid cards do not have expiration dates. Though we have expiration dates on many of our other cards. For example, my drivers’ license expires January 7, 2018. My VISA expires April 18, 2018.

Most Medicaid cards are annually renewed, as well. Someone who is eligible for Medicaid one year may not be eligible the next.

medicaid card

Our Medicaid cards, generally, have an issuance date, but not an expiration date. The thought is that requiring people to “re-enroll” yearly is sufficient for eligibility status.

Similar to my CostCo card. My Costco card expires annually, and I have to renew it every 12 months. But my CostCo card is not given to me based on my personal circumstances. I pay for the card every year, which means that I can use the card all year, regardless whether I move, get promoted, or decide that I never want to shop at CostCo again.

Medicaid cards, on the other hand, are based on a person’s or family’s personal circumstances.

A lot can happen in a year causing someone to no longer be eligible for Medicaid.

For example, a Medicaid recipient, Susan, could qualify for Medicaid on January 1, 2015, because Susan is a jobless and a single mother going through a divorce. She has a NC Medicaid card issued on January 1, 2015. She presents herself to your office on March 1, 2015. Unbeknownst to you, she obtained a job at a law office in February (Susan is a licensed attorney, but she was staying home with the kids when she was married. Now that she is divorced, she quickly obtained employment for $70,000/year, but does not contact Medicaid. Her firm offers health insurance, but only after she is employed over 60 days. Thus, Susan presents herself to you with her Medicaid card).

If Susan presents to your office on March 1, 2015, with a Medicaid card issued January 1, 2015, how many of you would double-check the patients eligibility in the NCTracks portal?

How many would rely on the existence of the Medicaid card as proof of eligibility?

How many of you would check eligibility in the NCTRacks portal and print screen shot showing eligibility for proof in the future.

The next question is who is liable for Susan receiving Medicaid services in March when she was no longer eligible for Medicaid, but held a Medicaid card and, according to the NCTracks portal, was Medicaid eligible??

  • Susan?
  • You, the provider?
  • DHHS?
  • NCTracks?

Do you really have to be the HUGE billy goat to avoid troll-ish recoupments?

Susan’s example is similar to dental services for pregnant women on Medicaid for Pregnant Women (MPW). MPW expires when the woman gives birth. However, the dentists do not report the birth of the child, the ob/gyn does. Dentists have no knowledge of whether a woman has or has not given birth. See blog.

MPW expires upon the birth of the child, and that due date is not printed on the MPW card.

I daresay that the dentists with whom I have spoken have assured me that every time a pregnant woman presents at the dental or orthodontic offices that an employee ensures that the consumer is eligible for dental services under MPW by checking the NCTracks portal. (Small billy-goat). Some dentists go so far to print out the screenshot on the NCTracks portal demonstrating MPW eligibility (HUGE billy-goat), but such overkill is not required by the DMA Clinical Coverage Policies.

If the clinical policies, rules, and regulations do not require such HUGE billy-goat nonsense, how can providers be held up to the HUGE billy-goat standard? Even the puny billy-goat is, arguably, reasonably compliant with rules, regulations, and policies.

NCTracks is not current; it is not “live time.” Apparently, even if the woman has delivered her baby, the NCTracks portal may still show that the woman is eligible for MPW. Maybe even for months…

Is the eligibility fallacy that is confirmed by NCTracks, the dentists’ fault?

Well, over three (3) years from its go-live date, July 1, 2013, NCTracks may have finally fixed this error.

In the October 2015 Medicaid Bulletin, DHHS published the following:

Attention: Dental Providers

New NCTracks Edits to Limit Dental and Orthodontic Services for Medicaid for Pregnant Women (MPW) Beneficiaries

On Aug. 2, 2015, NCTracks began to deny/recoup payment of dental and orthodontic services for beneficiaries covered under the Medicaid for Pregnant Women (MPW) program if the date of service is after the baby was delivered. This is a longstanding N.C. Medicaid policy that was previously monitored through post-payment review.

According to N.C. Division of Medical Assistance (DMA) clinical coverage policy 4A, Dental Services:

For pregnant Medicaid-eligible beneficiaries covered under the Medicaid for Pregnant Women program class ‘MPW,’ dental services as described in this policy are covered through the day of delivery.

Therefore, claims for dental services rendered after the date of delivery for beneficiaries under MPW eligibility are outside the policy limitation and are subject to denial/recoupment.

According to DMA clinical coverage policy 4B,Orthodontic Services:

Pregnant Medicaid-eligible beneficiaries covered under the Medicaid for Pregnant Women program class ‘MPW’ are not eligible for orthodontic services as described in this policy.

Therefore, claims for orthodontic records (D0150, D0330, D0340, and D0470) or orthodontic banding (D8070 or D8080) rendered for beneficiaries under MPW eligibility are outside of policy limitation and are subject to denial/recoupment.

Periodic orthodontic treatment visits (D8670) and orthodontic retention (D8680) will continue to be reimbursed regardless of the beneficiary’s eligibility status at the time of the visit so long as the beneficiary was eligible on the date of banding.

Seriously? “Now I’m coming to gobble you up!!”

August 2, 2015, is over two years after NCTracks went live.

In essence, what DHHS is saying is that NCTracks was inept at catching whether a female Medicaid recipient gave birth. Either the computer system did not have a way for the ob/gyn to inform NCTracks that the baby was delivered, the ob/gyn did not timely submit such information, or NCTracks simply kept women as being eligible for MPW until, months later, someone caught the mistake. And, because of NCTracks’ folly, the dentists must pay.

How about, if the portal for NCTracks state that someone is eligible for MPW, then providers can actually believe that the portal is correct??? How about a little accountability, DHHS???

If you take MPW and want to avoid potential recoupments, you may need some pregnancy tests in your bathrooms.

DHHS is expecting all dentists to be the HUGE bill goat. Are these unreasonable expectations? I see no law, rules, regulations, or policies that require dentists to be the HUGE billy goat. In fact, the small and puny may also be compliant.

“You don’t always have to be HUGE, the puny and small are equally as smart.”

Federal Audit Spurs NC to Recoup from Dentists Who Accept MPW!!

When providers receive Tentative Notices of Overpayment (TNOs), we appeal the findings. And, for the most part, we are successful. Does our State of NC simply roll over when the federal government audits it??

A recent audit by Health and Human Services (HHS) Office of Inspector General (OIG) finds that:

“We recommend that the State agency:

  • refund $1,038,735 to the Federal Government for unallowable dental services provided to MPW beneficiaries after the day of delivery; and
  • increase postpayment reviews of dental claims, including claims for MPW beneficiaries, to help ensure the proper and efficient payment of claims and ensure compliance with
    Federal and State laws, regulations, and program guidance.”

MPW is Medicaid for Pregnant Women.  Recently, I had noticed that a high number of dentists were receiving TNOs.  See blog.  I hear through the grapevine that a very high number of dentists recently received TNOs claiming that the dentists had rendered dental services to women who had delivered their babies.

Now we know why…

However, my question is: Does NC simply accept the findings of HHS OIG without requesting a reconsideration review and/or appeal?

It seems that if NC appealed the findings, then NC would not be forced to seek recoupments from health care providers.  We already have a shortage of dentists for Medicaid recipients.  See blog and blog.

And if the federal auditors audit in similar fashion to our NC auditors, then the appeal would, most likely, be successful. Or, in the very least, reduce the recouped amount, which would benefit health care providers and taxpayers.

Whenever NC receives a federal audit with an alleged recoupment, NC should fight for NC Medicaid providers and taxpayers!!  Not simply roll over and pay itself back with recoupments!

This audit was published March 2015.  It is September.  I will look into whether there is an appeal on record.

Have an Inkling of a Possible Overpayment, You Must Repay Within 60 Days, Says U.S. District Court!

You are a health care provider.  You own an agency.  An employee has a “hunch” that…

maybe…

perhaps….

your agency was overpaid for Medicare/caid reimbursements over the past two years to the tune of $1 million!

This employee has been your billing manager for years and you trust her…but…she’s not an attorney and doesn’t have knowledge of pertinent legal defenses. You are concerned about the possibility of overpayments, BUT….$1 million? What if she is wrong?  That’s a lot of money!

According to a recent U.S. District Court in New York, you have 60 days to notify and refund the government of this alleged $1 million overpayment, despite not having a concrete number or understanding whether, in fact, you actually owe the money.

Seem a bit harsh? It is.

With the passage of the Affordable Care Act (ACA) on March 23, 2010, many new regulations were implemented with burdensome requirements to which health care providers are required to adhere.  At first, the true magnitude of the ACA was unknown, as very few people actually read the voluminous Act and, even fewer, sat to contemplate the unintentional consequences the Act would present to providers. For example, I daresay that few, if any, legislators foresaw the Draconian effect from changing the word “may” in 42 CFR 455.23 to “must.” See blog and blog and blog.

Another boiling frog in the muck of the ACA is the 60-Day Refund Rule (informally the 60-day rule).

What is the 60-Day Refund Rule?

In 2012, CMS proposed the “60-day Refund Rule,” requiring Medicare providers and suppliers to repay Medicare overpayments within 60 days of the provider or supplier identifying the overpayment.  Meaning, if you perform a self audit and determine that you think that you were overpaid, then you must repay the amount within 60 days or face penalties.

If I had a nickel for each time a clients calls me and says, “Well, I THINK I may have been overpaid, but I’m not really sure,” and, subsequently, I explained how they did not owe the money, I’d be Kardashian rich.

It is easy to get confused. Some overpayment issues are esoteric, involving complex eligibility issues, questionable duplicity issues, and issues involving “grey areas” of “non”-covered services.  Sometimes a provider may think he/she owes an overpayment until he/she speaks to me and realizes that, by another interpretation of the same Clinical Coverage Policy that, in fact, no overpayment is owed. To know you owe an overpayment, generally, means that you hired someone like me to perform the self audit.  From my experience, billing folks are all too quick to believe an overpayment is owed without thinking of the legal defenses that could prevent repayment, and this “quick to find an overpayment without thinking of legal defenses” is represented in Kane ex rel. United States et al. v. Healthfirst et al., the lawsuit that I will be discussing in this blog.  And to the billings folks’ credit, you cannot blame them.  They don’t want to be accused of fraud. They would rather “do the right thing” and repay an overpayment, rather than try to argue that it is not due.  This “quick to find an overpayment without thinking of legal defenses” is merely the billing folks trying to conduct all work “above-board,” but can hurt the provider agency financially.

Nonetheless, the 60-day Refund Rule is apathetic as to whether you know what you owe or whether you hire someone like me.  The 60-Day Refund Rule demands repayment to the federal government upon 60-days after your “identification” of said alleged overpayment.

Section 1128(d)(2) of the Social Security Act states that:

“An overpayment must be reported and returned under paragraph (1) by the later of— (A) the date which is 60 days after the date on which the overpayment was identified; or (B) the date any corresponding cost report is due, if applicable.”

A recent case in the U.S. District Court of New York has forged new ground by denying a health care providers’ Motion to Dismiss the U.S. government’s and New York State’s complaints in intervention under the False Claims Act (FCA).  The providers argued that the 60-day rule cannot start without a precise understanding as to the actual amount of the overpayment. Surely, the 60-day rule does not begin to run on the day someone accuses the provider of a possible overpayment!

My colleague, Jennifer Forsyth, recently blogged about this very issue.  See Jennifer’s blog.

Basically, in Kane ex rel. United States et al. v. Healthfirst et al., three hospitals provided care to Medicaid patients. Due to a software glitch [cough, cough, NCTracks] and due to no fault of the hospitals, the hospitals received possible overpayments.  The single state entity for Medicaid in New York questioned the hospitals in 2010, and the hospitals took the proactive step of tasking an employee, Kane, who eventually became the whistleblower, to determine whether, if, in fact, the hospital did receive overpayments.

At this point, arguably, the hospitals were on notice of the possibility of overpayments, but had not “identified” such overpayments per the 60-day rule.  It was not until Kane made preliminary conclusions that the hospitals were held to have “identified” the alleged overpayments.  But very important is the fact that the Court held the hospitals liable for having “identified” the alleged overpayments prior to actually knowing the veracity of the preliminary findings.

Five months after being tasked with the job of determining any overpayment, Kane emails the hospital staff her findings that, in her opinion, the hospitals had received overpayments totaling over $1 million for over 900 claims.  In reality, Kane’s findings were largely inaccurate, as approximately one-half of her alleged findings of overpayments were actually paid accurately.  Despite the inaccurate findings, the Complaint that Kane filed as the whistleblower (she had been previously fired, which may or may not have contributed to her willingness to bring a whistleblower suit), alleged that the hospitals had a duty under the 60-day rule to report and refund the overpayments, even though there was no certainty as to whether the findings were accurate. And the Court agreed with Kane!

Even more astounding, Kane’s email to the hospitals’ management that contained the inaccurate findings contained phrases that would lead one to believe that the findings were only preliminary:

  • “further analysis would be needed to confirm his findings;” and
  • the spreadsheet provided “some insight to the magnitude of the problem” (emphasis added).

The above-mentioned comments would further the argument that the hospitals were not required to notify the Department and return the money 60 days from Kanes’ email because Kane’s own language within the email was so wishy-washy. Her language in her email certainly does not instill confidence that her findings are accurate and conclusive.

But…

The 60-day rule requires notification and return of the overpayments within 60 days of identification.  The definition of “identification” is the crux of Kane ex rel. United States et al. v. Healthfirst et al. [it depends on what the definition of “is” is].

The Complaint reads, that the hospitals “fraudulently delay[ed] its repayments for up to two years after the Health System knew” the extent of the overpayments” (emphasis added). According to the Complaint, the date that the hospitals “knew” of the overpayment was the date Kane emailed the inaccurate findings.

The hospitals filed a Motion to Dismiss based on the fact that Kane’s email and findings did not conclusively identify overpayments, instead, only provided a preliminary finding to which the hospitals would have needed to verify.

The issue in Kane ex rel. United States et al. v. Healthfirst et al. is the definition of “identify” under the 60-day rule. Does “identify” mean “possibly, maybe?” Or “I know I owe it?” Or somewhere in between?

The hospitals filed a Motion to Dismiss, claiming that the 60-day rule did not begin to run on the date that Kane sent his “preliminary findings.”  The U.S. District Court in New York denied the hospitals’ Motion to Dismiss and stated in the Order, “there is an established duty to pay money to the government, even if the precise amount due is yet to be determined.” (emphasis added).

Yet another heavy burden tossed upon health care providers in the ever-deepening, regulatory muck involved in the ACA.  As health care providers carry heavier burdens, they begin to sink into the muck.

Important take aways:

  • Caveat: Take precautions to avoid creating disgruntled, former employees.
  • Have an experienced attorney on speed dial.
  • Self audit, but self audit with someone highly experienced and knowledgeable.
  • Understand the ACA. If you do not, read it. Or hire someone to teach you.

Consider Nominating This Blog for the 2015 Best Legal Blog Contest (Please)!

The 2015 Legal Blog Contest is here!

For all you that follow this blog, thank you!  I hope that you agree that I provide you with valuable and up-to-date information on Medicaid/care regulatory issues.  At least, that is my hope in maintaining this blog.  And maintaining this blog takes a lot of time outside my normal, hectic legal career and my time as a mom and wife.  Don’t get me wrong…I love blogging about these issues because these issues are near and dear to my heart.  I am passionate about health care, health care providers, Medicaid and Medicare, and access to quality care.

If you are a follower, then you know that I try to keep my readers current on Medicaid/care fraud, federal and state laws, legal rights for health care providers, bills in the General Assembly germane to health care, extrapolation issues, CMS rulings, managed care matters, reimbursement rates, RAC audits and much, much more!

If you enjoy my blog, I ask a favor. Please consider nominating my blog for the 2015 Best Legal Blog Contest.

If you want to nominate my blog, please click here.

Scroll down until you see this:

blog contest

Enter your name, email address, my blog address. which is:

https://medicaidlawnc.wordpress.com/

For category, click on “Niche and Specialty.”  I do not believe the other categories correctly describe my blog.

And type a reason why you enjoy my blog.  Much appreciated!

Going to the Dentist? You May Need to Take a Pregnancy Test!

I go to the dentist for teeth cleaning. I go to an ob/gyn for my lady parts. They each are not entwined.

Recently, a number of dentists have contacted me they are receiving Tentative Notices of Overpayment (TNOs) stating that they owe money back to the state for dental services completed on women who had already given birth.

What?

First, what is Medicaid for Pregnant Women?

Basically, Medicaid for Pregnant Women (MPW) is a self-defining type of Medicaid coverage.  It is Medicaid coverage for pregnant women.

According to DHHS, “Medicaid for Pregnant Women (MPW) only covers services related to pregnancy:

  • Prenatal care, delivery and 60 days postpartum care
  • Services to treat medical conditions which may complicate the pregnancy (some services require prior approval)
  • Childbirth classes
  • Family planning services

A pregnant woman may apply for this program before or after she delivers. A woman who has experienced a recent pregnancy loss may also be eligible.”

And routine dental services are covered for MPW recipients through the date of delivery.

But, the day after the child is born…BOOM…no routine dental visits.

Here is a hypothetical example of this new issue that I have recently been made aware:

Mary is pregnant and is covered by MPW.  She makes a dental appointment for August 1, 2015.  She is due September 1, 2015.  She gives birth to a bouncing, baby boy, whom she names Paul on July 28, 2015.  Even though Paul is early, he is healthy (this is a happy hypothetical).  She shows up for her dental appointment with Dr. Peter on August 1, 2015.

Herein lies a delicate subject…due to its sensitive nature, I will now revert the hypothetical to myself, personally, and only for this narrow topic.

I had my beautiful 10-year old daughter at 28 weeks.  She came three months early. Despite the early delivery, I had expanded in the stomach area at least as much as a normal pregnant woman, if not more so.  Chalk it up to Harris Teeter birthday cakes. After my daughter was born, the insensitive, yet rule-following nurse actually had the audacity to place me on a scale (while I was conscious and alert!).  I was horrified to discover that after all that I went through that I had lost a mere 4 pounds.  She must have seen my look because she quickly explained that I had been pumped with so much fluid during the procedure that my weight was inflated. Likely story, I thought.  The point of this short anecdote is that I looked the same after giving birth that I did prior to giving birth.  Embarrassingly, my transition back to a normal, un-pregnant body extended for a much longer than expected period of time. Chalk it up to Harris Teeter birthday cakes.

Ok, going back to our hypothetical…

Mary really wants her teeth cleaned because, once she gives birth, she knows full well that she will not be able to undergo a teeth cleaning.  So when she presents herself at Dr. Peter’s  office and Dr. Peter asks whether she is still pregnant, she answers, “Yes, sir.”

Dr. Peter, undergoing all the due diligence that a dentist can be expected, has his assistant log on to NCTracks.  According to NCTracks, Mary is eligible for MPW. No changes are noted on her eligibility.  Satisfied with his due diligence, Dr. Peter cleans Mary’s teeth.

Two years later, Dr. Peter receives a TNO stating that he owes $10,000 back for services rendered to women after they gave birth.

Dr. Peter conducted his due diligence.  Dr. Peter inquired as to the pregnancy status to the patient.  Dr. Peter checked eligibility status with NCTracks.

What more would the state expect Dr. Peter do to determine whether his dental patients are indeed still pregnant? Ask them to pee in a cup? Hire a onsite ob/gyn?

You can imagine the consequences of each.

Yet, according to a number of dentists who have communicated with me, the state is placing the burden of knowing whether the dental patient is still pregnant on the dentist.

Talk about accountability! If NCTracks shows that the patient is eligible for MPW, shouldn’t NCTracks be held liable instead of the dentist?

Call me crazy, but I may or may not be extremely angry if my dentist asks me to pee in cup.

Obama’s Executive Order, Its Impact on Health Care Costs, and the Constitutionality of Executive Orders

Pres. Barack Obama will address the nation tonight at 8 pm (Thursday, November, 20, 2014). He is expected to discuss his executive order that will delay deportations of up to 5 million migrants.

What does an executive order on immigration have to do with Medicaid? Well, you can bank on the fact that almost none of the 5 million people has private health care coverage….which means, there is a high likelihood that most, if not all, the people would qualify for Medicaid.

With the expansion of Medicaid in many states, adding another 5 million people to the Medicaid program would be drastic.  Think about it…in NC, approximately 1.8 million people rely on Medicaid as their insurance.  5 million additional Medicaid recipients would be like adding 3 more North Carolinas to the country.

So I looked into it…

The Kaiser Family Foundation website states that even immigrants who have been in America over 5 years are sometimes still barred from getting Medicaid and those people would remain uninsured.  The Kaiser website states that under current law “some lawfully present immigrants who are authorized to work in the United States cannot enroll in Medicaid, even if they have been in the country for five or more years.”

By law, only immigrants who have green cards are entitled to enroll in Medicaid or purchase subsidized health care coverage through the ACA. Usually those immigrants with green cards are on the course to become citizens.

Regardless of whether Obama’s executive order tonight will or will not allow the 5 million people Medicaid coverage (which it will not), the executive order absolutely will greatly increase health care costs

The truth is that, with or without Obama’s executive order, the government already funds some health care for undocumented immigrants. We have an “emergency Medicaid” program and it pays hospitals to provide emergency and maternity care to immigrants if: 1) he or she otherwise would be Medicaid eligible if they weren’t in the country illegally or 2) he or she are legally present in this country for less than 5 years.  (Which is the reason that ER wait times are so long…if you have no health insurance and you get sick, the ER is precisely where you go).

However, with the additional 5 million people living within the borders of USA, it is without question that the “emergency Medicaid” funds will sharply escalate as hospitals provide more emergency care. ER waits times will, inevitably, increase. Health care costs, in general, surge as the population increases.  And the addition of 5 million folks in America is not a “natural” increase in population.  It will be like we added additional states.  Overnight and with the stroke of a pen, our population will grow immensely.  I guess we will see whether we get “growing pains.”

An act of Congress will still be required before the undocumented immigrants impacted by the executive order would be allowed to participate in the Medicaid programs and the Children’s Health Insurance Program (CHIP) coverage.

As to the Constitutionality of executive orders…

Executive orders are not specifically mentioned in the Constitution.  Many people interpret the nonexistence of executive orders in the Constitution as barring executive orders.

Article I Section I of the Constitution clearly states that all legislative powers reside in Congress. However, an executive order is not legislation. Technically, an executive order is a policy or procedure issued by the President that is a regulation that applies only to employees of the executive branch of government.

Nonetheless, our country has a vast history of president’s issuing executive orders. Abraham Lincoln issued an executive order to engage military in the Civil War, Woodrow Wilson issued an executive order arming the military before we entered World War I, and Franklin Roosevelt approved Japanese internment camps during World War II with an executive order.

Regardless of your political affiliation, in my opinion, it is very interesting that Obama would initiate an executive order regarding immigration given his past statements over the years complaining about past presidents’ executive orders being unconstitutional.

In 2008 campaign speeches, Obama regularly emphasized the importance of civil liberties and the sanctity of the Constitution.

In fact, in speeches, Obama stated, “most of the problems that we have had in civil liberties were not done through the Patriot Act, they were done through executive order by George W. Bush. And that’s why the first thing I will do when I am president is to call in my attorney general and have he or she review every executive order to determine which of those have undermined civil liberties, which are unconstitutional, and I will reverse them with the stroke of a pen.”

Whether or not people believe that executive orders are constitutional, it is indisputable that presidents on both sides of the aisle have issued executive orders.

Reagan and Bush issued executive orders. Although there is an argument that those executive orders came on the heels of congressional bills, as adjustments. Neither Reagan nor Bush simply circumvented Congress.

Going back to tonight’s anticipated executive order allowing 5 million migrants to remain in America…

While the executive order will not allow the 5 million people immediate access to Medicaid and other subsidized health care, it will allow 5 million more uninsured people to exist in America, which will, undoubtedly, increase health care costs and ER visits. And, eventually, the additional 5 million people will be eligible for Medicaid, subsidized health care, and all other benefits of living in America.

Haven’t Fixed Medicaid Yet…But I Haven’t Gotten Bucked Off Yet

There are a number of federal regulations that, if I were in charge, would be immediately amended. Obviously, I am not in charge, so despite my best blogging efforts, my blogs do not change federal law. Today, however, I had the honor and privilege to speak to someone who may have the clout and political pull to fix some of the calamities found in the Code of Federal Regulations (CFRs) that are so detrimental to health care providers who accept Medicare and Medicaid across the country.

My husband, daughter, and I ride horses nearly every weekend. We ride Western and on trails all over North Carolina and Virginia, mostly on charity rides. And over the past few years, I have, sadly, gone through over 5 horses. Not because the horses have passed. But because each horse had an oddity or behavior issue that either (a) I didn’t want to deal with; or (2) terrified me.

For example, Twist of Luck (Twist) is a gorgeous pure, white horse with a yellow tail and mane and brilliant, blue eyes. But he was what you call, “proud cut.” Meaning that because he sired so many foals, even after he became a gelding he thought like a stallion. One weekend we were at Uwharrie National Park and when I saddled up Twist and mounted him, he decided that he did not want me on his back. My husband said Twist looked like a “poster horse” for a rodeo with his back completely rounded like an angry cat and all four of his hooves in the air. Needless to say, I found myself quite quickly on the ground with a sore tooshie, and Twist found himself sold.

Since I do not have the time to actually train my horse, I need a trained horse.

With my hobby of horseback riding, a well-trained horse is imperative…not only for safety, but for my enjoyment as well.

In the area of Medicare and Medicaid, it is imperative for enough physicians, dentists, and other health care providers to accept Medicare and Medicaid. You see, health care providers choose to accept Medicare and Medicaid. And not all health care providers agree to accept Medicare or Medicaid. But it is important for enough health care providers to accept Medicare and Medicaid patients otherwise the Medicare or Medicaid card in a person’s hand is worthless. Same as Twist was worthless to me that day in Uwharrie. If you can’t ride a horse, what is the point of owning it? If you can’t find a health care provider, what is the use of having coverage?

Here in North Carolina, we decided to not expand Medicaid. This blog is not going to address the ever-growing discontent in the media as to the decision, although you can see my blog: “Medicaid Expansion: Bad for the Poor.”

Instead, this blog will address my idea that I pitched to Congresswoman Renee Ellmers over lunch last week and discussed today with her legislative counsel today as to how it can be implemented.

Here’s my idea:

According to most data, not expanding Medicaid in North Carolina is affecting approximately 1.6 million uninsured North Carolinians. But to my point of the shortage of health care providers accepting Medicaid, what is the point of having an insurance card that no health care provider accepts? Therefore, I propose a pilot program here in NC…a pilot program to help the approximate 1.6 million uninsured in NC. Besides the moral issue that everyone deserves quality health care, fiscally, it is sound to provide the uninsured with quality health care (notice that I did not say to provide the uninsured with Medicaid). When the uninsured go to emergency rooms it costs the taxpayers more than if the uninsured had an insurance policy that would allow primary care and specialty doctor appointments. But with Medicaid…you can count out most specialty care, even some basic necessary care like dental care.

Most of the uninsured in NC are non-disabled men. I say this because it is usually easier to get a child on Medicaid with the Early, Periodic, Screening, Diagnostic, Testing (EPSDT) laws. See my blog: “How EPSDT Allows Medicaid Recipients Under the Age of 21 To Receive More Services Than Covered by the State Plan” for an explanation of EPSDT. Many women receive Medicaid based on having dependent children. “In most states, adults without dependent children are ineligible for Medicaid, regardless of their income, and income limits for parents were very low—often below half the poverty level.” See Kaiser Foundation. Which means, generally, many of our uninsured are men without dependents. However, that does not mean they are not fathers. Many of the uninsured are fathers.

Two-thirds of the uninsured live in families where there is at least one full-time worker. However, the percentage of uninsured who live in families with no workers, part-time workers and only one full-time worker has increased 12 percentage points over 5 years. See Demographics.

So how do we help the uninsured without merely handing all uninsured a Medicaid card that will not give them quality health care because not enough trained health care providers accept Medicaid patients?

By giving the uninsured health care insurance, of course! But not Medicaid coverage…oh, no! By giving the uninsured private insurance that will be accepted by all health care providers, all specialists, all durable medical equipment companies, all dentists…

We could partner up with a larger insurer like Blue Cross Blue Shield (BCBS) and create a premium health care insurance on which the insured would pay no premiums or co-pays. Instead, federal grant money would cover the premiums. All that money that NC did not receive based on our decision to not expand Medicaid…can go toward this pilot program to purchase the private insurance for the uninsured.

In order to qualify for this premium, free, private insurance the person must:

1. Be a legal resident;
2. NOT qualify for Medicaid; and
3. Maintain a part time job.

The reasoning behind the criterion of maintaining a part-time job is simple.

It is indisputable that the Affordable Care Act (ACA) has motivated employers across America to decrease the number of full-time jobs due to the mandatory expense of employers providing health care to full-time employees.

Obviously, part-time work does not pay well. It is difficult to even maintain a living on part-time work’s low hourly wages. Many people are forced to hold down two-part time jobs in order to survive. If you can not work and receive more government hand outs, what is the incentive to work?

If my idea comes to fruition and many of our uninsured carry a private insurance card and receive quality health care from the providers of their choice, we could create a whole new group of North Carolinians not only contributing to the community by working, but also contributing to their own homes, and improving themselves and those around them.

I don’t want to provide anyone a useless piece of paper that does not provide quality health care. We may as well give everyone a “proud cut” horse that no one could ride.

Thank you, Congresswoman Renee Ellmers, for being willing to listen to me regarding the uninsured and actually follow-up with the intent to implement.

Quality health care is imperative. Necessary. Needed. We need to fix this system.