Category Archives: ACTT Services

NC State Auditor’s Findings May Cause Overzealous Oversight

Ok, so it took me a couple of days to free up some time to discuss the most recent Performance Audit by our State Auditor. This time of year is CRAZY! We had to get our daughter ready for the 4th grade, which entails buying an absurd amount of school supplies. Thank goodness we don’t have to do “back to school” clothes shopping, because she wears uniforms. Yesterday was her first day of school and, apparently, everything went well.

Now, I want to discuss the recent Performance Audit published by Beth Wood, our NC State Auditor, regarding provider eligibility. Prior to going any further, let me voice my opinion that Beth Wood as our State Auditor rocks. She is smart, courageous, and a force of nature. Any comment that may be negative in nature as to the most recent audit is NOT negative as to the audit itself, but to the possible consequences of such an audit. In other words, I do not believe that the Performance Audit as to Medicaid Provider Eligibility is incorrect; I am only concerned as to the possible consequences of such an audit on the Department of Health and Human Services (DHHS) and health care providers.

The Medicaid Provider Eligibility Performance Audit found that “deficiencies in the enrollment process increase the risk of unqualified providers participating in the Medicaid Program.”

And DHHS’ “enrollment review procedures do not provide reasonable assurance that only qualified providers are approved to participate in the NC Medicaid program.”

And “quality assurance reviews were not conducted or were ineffective.”

Basically, the Performance Audit (in layman’s terms) says that DHHS, again, has little to no oversight, lacks supervision over providers, has program deficiencies, and lacks the ability to manage Medicaid provider eligibility requirements adequately. Considering that DHHS is the single agency charged with managing Medicaid in North Carolina, the Performance Audit is yet another blow to the ability of DHHS to do its job.

Gov. McCrory appointed Sec. Aldona Wos as the head of DHHS, effective January 5, 2013. With Sec. Wos at its helm, DHHS has been riddled by the media with stories of management difficulties, high-level resignations, and mismanaged tax dollars. With the amount of media attention shining on DHHS, it is amazing that Sec. Wos has only been there almost a year and a half. Oh, how time flies.

While, again, I do not discount the accuracy of the Medicaid Provider Eligibility Performance Audit, I am fearful that it will spur DHHS to almost another “Salem witch hunt” extravaganza by pushing the already far-swung pendulum of attacks on providers, in the direction of more attacks. DHHS, through its contractors, agents and vendors, has increased its regulatory audits and heightened its standards to be compliant as a provider for a number of reasons:

1. The U. S. Supreme Court’s Olmstead case;
2. The DOJ settlement as to ACTT providers;
3. More oversight by CMS;
4. The ACA’s push for recovery audit contractors (RACs);
5. General need to decrease the Medicaid budget;
6. Increased fraud, waste, and abuse detection standards in the ACA;
7. Monetary incentives on managed care organizations (MCOs) to decrease the number of providers;
8. Etc.

Imagine a pendulum swinging…or, better yet, imagine a child swinging on a swing. Before the child reaches the highest point of the swing, an adult runs behind the child and pushes the child even higher, in order to get a little more “umphf” on the swing. And the child goes even higher and squeals even more in excitement. But that’s not always a great idea. Sometimes the child goes flying off.

I am afraid that the Performance Audit will be that adult pushing the child on the swing. The extra little push…the extra little “umphf” to make the pendulum swing even higher.

As with any Performance Audit, DHHS is allowed to respond to Ms. Wood’s findings. One response is as follows:

“In September 2013, DMA established and implemented Management Monitoring Quality Controls (Monitoring Plan) for reviewing approval and denial decisions related to provider applications referred to it by the Contractor due to a potential concern. The Monitoring Plan established standardized policies and procedures and ensures that staff adheres to them in making enrollment determinations.”

In other words, recently DHHS has put forth a more aggressive oversight program as to health care providers and it will only get more aggressive.

In the last year or so, we have seen more aggressive oversight measures on health care provider that accept Medicaid. More audits, more desk reviews, more fraud investigation…and most (that I have seen) are overzealous and incorrect.

Believe me, I would be fine with increased oversight on health care providers, if the increased oversight was conducted correctly and in compliance with federal and state rules and regulations. But the audits and oversight to which I have been privy are over-bearing on providers, incorrect in the findings, and lacking much of due process for, much less respect to the providers.

I am concerned that the extra little “umphf” by this Performance Audit will impact health care providers’ decisions to accept or not to accept Medicaid patients. See my past blogs on the shortage of health care providers accepting Medicaid.  “Shortage of Dentists Who Accept Medicaid: The Shortage Continues.” “Provider Shortage for Medicaid Recipients.” And “Prisons and Emergency Rooms: Our New Medicaid Mental Health Care Providers.

Instead of increasing overzealous audits on health care providers, maybe we should require DHHS, through its contractors, agents, and vendors, to conduct compliant, considerate, and constitutionally-correct audits and oversight. Maybe the “umphf” should be applied more toward DHHS.

Knicole Emanuel to Appear on UNC-TV Tonight! Tune In at 7:30pm!

Heather Burgiss, a UNC-TV journalist, created a 3-part television series called, “Mental Health Services in NC.” Part 1 will air tonight on UNC-TC at 7:30, and I will be discussing the important topic of the current status of our mental health system in NC.  So tune in to watch!!!!

The three-part series is intended to educate North Carolinians on the current state of mental health in NC, as well as discuss the upcoming Medicaid reform consisting of the Accountable Care Organizations (ACOs) for physical health services.

P.S. It is intimidating how UNC-TV interviews you, so forgive any bad grammar, etc. 🙂  During the interview, they cut off all the lights and shine a bright light on you.  It creates a strange environment in which you can hear the person asking you questions, but you cannot see him or her.  Plus, the light is super hot.

But, we will see, Heather was very nice in dealing with my novice handling of the interview.

And, BTW, when you see the scene during which I am walking down the hall of my law firm, I had a strange sensation to start doing the MC Hammer.  But I did not succumb.

The Future of Managed Care in Medicaid and the Fear of the Unknown

The unknown.  No one likes the unknown.  Especially people, like me, who try so desperately to maintain control over our lives. 

But the future of Medicaid in North Carolina is unknown.  We have all heard Governor McCrory talk about expanding managed care to all Medicaid services, not just behavioral health care, but for all medical services.  Here in NC, our experience with managed care organizations (MCOs) has not been all sunshine and roses.  So, when we hear…let’s expand the MCO system to all Medicaid services, I am reminded of the feeling I had this past Saturday as I stood on the side of the Wells Fargo building, 30-stories up, facing background, with a harness and a helmet on, when the rappel guy said, “Ok…now lean back and let go…”

OK….so is anyone wondering how I managed rappelling down the 30-story Wells Fargo building downtown Raleigh this past Saturday in the name of Special Olympics North Carolina?

Answer: I DID NOT MANAGE WELL!!!

I do not kid you when I say that I thought that I would enjoy rappelling. I envisioned myself bouncing off the side of the building, laughing, and doing straddle jumps. I envisioned myself getting to the bottom with an adrenaline rush and an immediate need to sign-up for next year’s Over The Edge charity event.

So, what actually happened?  Picture this:

I am standing on the edge of a 30-story building.  I have 20 pounds of equipment attached all around my body.  I am donning a helmet and gloves.  I have never seen any of the equipment that is wrapped around my body.  The pro-rappellers are saying things like “rigger,” “descenders,” and “carabiners.”  They are obviously all hard-core, banging rapellers, which I, most certainly, am not.

In order to get on the ledge of the building, you have to climb up onto the ledge…as in, take your 2 arms and hoist your body up onto the ledge…sit down on your bum with your back to the 30-story view…and, then, completely stand up…. on a ledge… in order to lean back and jump off the building.

If you can envision preparing yourself for a jump off a 30-story building without your heart racing, then you are way cooler than I.

Ever heard the saying, “The first step is the hardest?”  Whoever said that had, obviously, rappelled off the Wells Fargo building.  Just prior to actually going over the edge, not only did my body have to battle the physical issues (shaking, breathing, and sweating), but my brain kicked into high gear.  I wanted to cry.  I cussed at the nice rappellers trying to comfort me.  My brain told me to give up and descend as we are meant to…via elevators.

The rappeller-volunteer said, “Lean back and let go!”

I cussed.  I screamed, “Get me off this building!!” to the nice rappeller-volunteers.  But, eventually (and, definitely, NOT gracefully) I started the descent down the building.  The entire way down, which, by the way, takes at least 15 minutes, I panicked; I hyperventilated; I prayed; I cussed; I tried to not spin; I made a very weak attempt of actually using the lever attached to my rope to make myself go down (No, I do not know the term for the apparatus); my muscles failed me….for 15 minutes.

Why?? Fear of the unknown.  I was in a completely new situation, and one in which I had no control.

Similarly, the unknowns of the future of Medicaid terrify providers, recipients, and advocates alike.  “Just lean back and let go!”

I am currently at the Association for Home and Hospice Care of North Carolina (AHHC) Leadership Convention in Wrightsville Beach.  (Which, BTW, is a great association).  The morning speaker, Scott Carbonara was fantastic.  He spoke about engaging fully in life, work, and family.

During lunch, I ended up sitting next to another attorney (unbeknownst to me at the time of sitting), who works for the National Council on Medicaid.

Another person who wants to talk about Medicaid sitting next to me during lunch? I felt like I drew the lucky straw.

Then she said that she helps implement managed care throughout the country.  She may as well have said that she teaches medical providers to refuse Medicaid and provide horrible services to Medicaid recipients.

You have to understand, if you have read my blogs, my opinion as to MCOs and mental health.

She must’ve read my horror on my face.  She said…”Oh, I know.  Most people do not have positive reactions when I explain my job.”

Me? I felt like I was standing on edge of the ledge with an unknown rappeller telling me to, “Lean back and let go!”  Trust me…

We proceeded to have a rather lengthy conversation.  I explained the effects of the MCOs on Medicaid recipients and behavioral health care providers here in NC. 

I explained to her that some MCOs are denying medically necessary assertive community treatment team services (ACTT) (a highly intense, 24-hour/day service for the most severely mentally ill) even when the recipients meet the continued stay criteria and do not meet discharge criteria.  I explained that the recipients who were undergoing discharge from ACTT were becoming hospitalized, incarcerated, homeless, and sometimes all of the above.

She was horrified.

“Why would the MCOs deny ACTT services if discharge criteria is not met?”  She said.  “It ends up costing more money, with the hospitalizations and incarcerations, than it would cost if the MCO actually authorized the mental health care needed.”  In other words, providing medically necessary services saves money, if you look at the totality of circumstances.

“Where is CMS?”

You win a prize! Ding! Ding! Ding!

I explained that our management of Medicaid services is bifurcated.  The MCOs are only in charge of behavioral health, not the total patient care.  The monetary incentive for the MCOs in NC is to provide the least expensive services to the least amount of Medicaid recipients through the least amount of Medicaid providers.

She said, “Well, the providers can choose to deal with the MCOs, right?”

Not in NC.  As the MCOs are jurisdictional, if the MCO in one county says that you cannot see your patients, another MCO in a different MCO may say otherwise.

She explained that her MCOs work completely differently.  (Here I was on the edge of the Wells Fargo building again).  We are just supposed to trust that other MCOs would act differently?

Then she told me why her MCOs would not act like our current MCOs.

In her MCO world, the MCOs manage ALL Medicaid services. If a recipient suffers high blood pressure, diabetes, and schizophrenia, the MCO handles all the recipients’ medical issues.  That MCO is in charge of the totality of the recipient’s care.  If the MCO denies ACTT services and the recipient is hospitalized, then the MCO has the burden of paying for that more expensive ER visit.  If the MCO denies ACTT services and the recipient is incarcerated without the proper care and medication, then that MCO has the burden of paying for all crisis care for the recipient that may occur from not receiving necessary services.  It costs less to provide proper care rather than let the recipient decompress and pay higher emergency costs. 

Hmmm…

She wanted to get a representative of one her MCOs to listen to my horror stories.  She tried to convince me that the MCOs she has worked with would approve all necessary services.  It’s just cheaper in the long run.

But, to me, there is fear of the unknown.

What if the MCOs she has worked with do NOT authorize services like she is describing??

How do we know that a new system would be better? I mean, we’ve all seen how great the new billing system NCTracks is…New is not always better.  Change is unknown, and the unknown is scary.

I guess we all have to ask ourselves: Is the current NC MCO system bad enough to warrant a change to the unknown?

When you are standing on top the 30-story building, and are told to “Lean back and let go…”

Do you?

Or do you take the elevators?

Smoke and Mirrors: ECBH Increasing Medicaid Rates (But Decreasing the Amount of Services Authorized?)

I am always amazed at magicians.  David Copperfield, David Blaine…

I once saw David Copperfield live.  I was convinced prior to the show that I would be able to determine how he performed the illusions. I just KNEW that I would see the strings or the trapdoor. But I did not. I was thoroughly amazed. Despite the fact that I still know that magic is not real, I was still awe-struck and entertained.  Realistically, magic is just smoke and mirrors. But, dag  on, those smoke and mirrors do a fantastic job.  At times, while watching a magic show, I find myself actually believing in magic. That is the power of smoke and mirrors.

Smoke and mirrors do not only appear in magic.  Many politicians are expert wielders of smoke and mirrors.  So to are many salesmen. And, apparently, East Carolina Behavioral Health (ECBH).

An article was published on NC Health News’ website yesterday. “Medicaid LME Updates: Cumberland/Alliance to Merge, Good News from ECBH.” Article is good. Information is good. But the ECBH news, I find “smoky.”

Click here for the article by Taylor Sisk

According to the article, “ECBH will increase the rates for psychological testing by 10 percent, personal care services by 16 percent, peer support by 7 percent and facility-based crisis and detoxification services to cover the full cost of the service.”

On the surface, the increase in rates that ECBH is implementing sounds great, right? In my head, I thought, “Wow! ECBH is doing some great marketing. Providers will want to work with ECBH…”

The problem is that the “surface level” or rate increase “on its face” is never the whole story. (Which is why ECBH’s rate increase is such an amazing use of smoke and mirrors. Most people will never see past the smoke).

The MCOs are prepaid. If the MCOs’ do NOT contract with providers and NOT authorize services, profits rise. 

But would an MCO REALLY deny medically necessary services, theoretically, to INCREASE profit?? You can decide.

However, one of my clients hired me because ECBH denied 100% of continuing authorizations and new referrals for ACTT services in Pitt County.

ONE HUNDRED PERCENT!

What are ACTT services?

DMA Clinical Policy 8A defines ACTT services:

The Assertive Community Treatment Team [ACTT] is a service provided by an interdisciplinary team that ensures service availability 24 hours a day, 7 days per week and is prepared to carry out a full range of treatment functions wherever and whenever needed. A service beneficiary is referred to the Assertive Community Treatment Team service when it has been determined that his or her needs are so pervasive or unpredictable that they cannot be met effectively by any other combination of available community services. Typically this service should be targeted to the 10% of MHDDSA service beneficiaries who have serious and persistent mental illness or co-occurring disorders, dual and triply diagnosed and the most complex and expensive treatment needs.” 

ACTT services are reserved for the extremely mentally ill.  These are the people who need 24-hour services; recipients receiving ACTT services are people who must receive the ACTT services to function.  Yet, ECBH denied 100% of my client’s new referrals and continuing authorizations.  One such denial was a Medicaid recipient who had been arrested 6 times since April 2012.  After the ACTT denial, the Medicaid recipient was again incarcerated, which is where the recipient is now.  Another denial resulted in the Medicaid recipient being hospitalized for suicidal ideation.

For recipients already receiving ACTT services, ECBH has forced my client to “step-down” the recipients to outpatient behavioral therapy (“OBT”). Of the Medicaid recipients that ECBH has forced Petitioner to “step-down,” three recipients were immediately referred back to ACTT when the OBT providers stated that the recipients suffered too high acuity of mental health illness to manage in OBT setting.  Two recipients were incarnated after discharge; the jail employees are complaining of psychiatric problems that are difficult to manage. 

Back in May 2013, the local news channel in Greenville, North Carolina, aired “9 On Your Side Mental Health Town Hall exposes problems, brings you answers.”  The news channel coverage demonstrates the possibility of the widespread breath of ECBH denials, in general. Maybe ECBH’s denials of medically necessary services is not limited to my client’s personal situation.

Regardless of the breadth of ECBH’s denials of medically necessary services, back in May 2013, ECBH was getting some bad marketing from the local news. So what does ECBH do? Raise reimbursement rates.

If, in fact, ECBH is denying many medically necessary Medicaid services in order to raise profit, then isn’t ECBH’s rate increase just smoke and mirrors?