Category Archives: ACTT

Managed Care – Eight Reasons Why MCOs Smell Like Pre-Minced Garlic

When it comes to the managed care organizations (MCOs) in NC, something smells rancid, like pre-minced garlic. When I first met my husband, Scott, I cooked with pre-minced garlic that comes in a jar. I figured it was easier than buying fresh garlic and dicing it myself. Scott bought fresh garlic and diced it. Then he asked me to smell the fresh garlic versus the pre-minced garlic. There was no contest. Next to the fresh garlic, the pre-minced garlic smelled rancid. That is the same odor I smell when I read information about the MCOs – pre-minced garlic in a jar.

garlic minced-garlic

In NC, MCOs are charged with managing Medicaid funds for behavioral health care, developmentally disabled, and substance abuse services. When the MCOs were initially created, we had 13. These are geographically situated, so providers and recipients have no choice with which MCO to interact. If you live in Sandhills’ catchment area, then you must go through Sandhills. If you provide services in Cardinal’s catchment area, then you must contract with Cardinal – even though you already have a provider participation agreement with the State of NC to provide Medicaid services in the State of NC.

Over the years, there has been consolidation, and now we have 7 MCOs.

newestmco

From left to right: Smoky Mountain (Duke blue); Partners Behavioral Health (Wake Forest gold); Cardinal Innovations Healthcare (ECU purple); Sandhills (UNCC green); Alliance Behavioral Healthcare (mint green); Eastpointe (Gap Khaki); and Trillium (highlighter yellow/green).

Recently, Cardinal (ECU purple) and Eastpointe (Gap khaki) announced they will consolidate, pending authorization from the Secretary of DHHS. The 20-county Cardinal will morph into a 32-county, MCO giant.

Here is the source of the rancid, pre-minced, garlic smell (in my opinion):

One – MCOs are not private entities. MCOs are prepaid with our tax dollars. Therefore, unlike Blue Cross Blue Shield, the MCOs must answer to NC taxpayers. The MCOs owe a duty of financial responsibility to taxpayers, just like the state government, cities, and towns.

Two – Cardinal CEO, Richard Topping, is paid $635,000, plus he has a 0 to 30 percent bonus potential which could be roughly another $250,000, plus he has some sort of annuity or long-term package of $412,000 (with our tax dollars).

Three – Cardinal is selling or has sold the 26 properties it owns or owned (with our tax dollars) to lease office space in the NASCAR Plaza office tower in uptown Charlotte for $300 to $400 per square foot plus employee parking (with our tax dollars).

Four – Cardinal charges 8% of public funds for its administrative costs. (Does that include Topping’s salary and bonuses?) How many employees are salaried by Cardinal? (with our tax dollars).

Five – The MCOs are prepaid. Once the MCOs receive the funds, the funds are public funds and subject to fiscal scrutiny. However, the MCOs keep whatever funds that it has at the end of the fiscal year. In other words, the MCOs pocket any money that was NOT used to reimburse a provider for a service rendered to a Medicaid recipient. Cardinal – alone – handles around $2.8 billion in Medicaid funding per year for behavioral health services. The financial incentive for MCOs? Terminate providers and reduce/deny services.

Six – MCOs are terminating providers and limiting access to care. In my law practice, I am constantly defending behavioral health care providers that are terminated from an MCO catchment area without cause or with erroneous cause. For example, an agency was terminated from their MCO because the agency had switched administrative offices without telling the MCO. The agency continued to provide quality services to those in need. But, because of a technicality, not informing the MCO that the agency moved administrative offices, the MCO terminated the contract. Which,in turn, puts more money in the MCO’s pocket; one less provider to pay.  Is a change of address really a material breach of a contract? Regardless – it is an excuse.

Seven – Medicaid recipients are not receiving medically necessary services. Either the catchment areas do not have enough providers, the MCOs are denying and reducing medically necessary services, or both. Cardinal cut 11 of its state-funded services. Parents of disabled, adult children write to me, complaining that their services from their MCO have been slashed for no reason….But the MCOs are saving NC money!

Eight – The MCOs ended 2015 with a collective $842 million in the bank. Wonder how much money the MCOs have now…(with our tax dollars).

Rancid, I say. Rancid!

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.

Is Sec. Aldona Wos Challenging the Goliath-Like MCOs? Will She Win?

I attended a Women in Leadership conference the other day. The keynote speaker asked for us to come up with a one sentence mantra or mission statement that we would use to describe our purpose in life.  I had never thought about what my life purpose is…my career?..being a mom?….being a wife?

As a woman, I was torn.  Was I a bad mom if I thought my “purpose of being” was my career?  Do all women feel this? Was I a bad wife if I thought my “purpose of being” was my career?  Does my career define me?  I decided that what defines me are the indirect consequences of my career? (i.e., those who benefit from my advocacy, but could never hire me).

So my mission statement came out on paper as: I am here in order to advocate for the voiceless.

I have a rare opportunity with my career choice to indirectly help Medicaid recipients (the voiceless) by serving the providers who serve recipients.  Obviously, Medicaid recipients cannot afford me or any other attorney.  But, by serving those that serve recipients, indirectly I am serving recipients.  For a more detailed explanation why I love my job, see my blog on Why I Have the Most Rewarding Career.

Sometimes, however, my job feels like I am David fighting Goliath.  No…the flea on David’s shoe while he is fighting Goliath.

In my own head, I have always felt that changing government policy (fighting DHHS) is a true David and Goliath story.

Which, finally, brings me to my point.  For those of you who have been reading my blogs, how many times have I blogged about MCOs not providing medically necessary mental heath care services??? Or Medicaid recipients being incarcerated or hospitalized because the MCOs were denying mental heath care services?  But never have I written that DHHS is not providing the medically necessary mental heath care services, quite frankly, because DHHS has stood back and allowed the MCOs to run rampant.

Since the inception of the MCOs statewide, in my opinion and from what I see every day, the MCOs have increasingly taken more and more steps to deny more services, terminate more provider contracts, and recoup more money from providers.  And DHHS has taken less and less steps to supervise, oversee or manage the MCOs.  By the MCOs increasingly having a “I can do what I want attitude,” and DHHS increasingly having a “I can’t tell an MCO what to do” attitude, when it comes to the MCOs, the MCOs’ power has grown while DHHS’ ability to manage the MCOs has shrunk.  Thus, in the behavioral health care world, the MCOs have morphed into the Goliaths.  DHHS is an onlooker, and I am still the flea on David’s shoe.

Thereby creating a counterintuitive situation in which Sec. Wos is David and the MCOs are the Goliath. (Normally DHHS would be Goliath).

I have written approximately 230 blogs. (really???).  I would wager a guess that over half of my blog topics have been MCOs denying medically necessary mental health services or MCOs reaping monetary rewards for terminating provider Medicaid contracts or denying services to Medicaid recipients.

The flea on the shoe of David fighting Goliath.

But….perhaps….last week….the flea was noticed.

Last week the Department of Health and Human Services (DHHS) (actually, Secretary Aldona Wos) announced a new mental health, substance abuse effort.

What is that new effort?

Sec. Wos announced, what she called the “Crisis Solutions Initiative.”  “DHHS estimated that there were 150,000 visits to emergency rooms in the state last year for addition-related issues or psychiatric conditions.”  See The Progressive Pulse blog.  Remember my blog, “Prisons and Emergency Rooms: Our New Mental Health Care Providers?”

Sec. Wos, in a written statement, states “With today’s announcement, we begin a focused, long-term effort to ensure that individuals and families who are experiencing a mental health or substance abuse crisis know where to turn for the help they need.  In turn, we can begin to reduce the tremendous burden that these issues place on hospital emergency departments and law enforcement.”

OMG…did she read my blog???? (And even more crazy….and agree???????)

Whether it was my blog, true statistics brought to her attention, or an epiphany, it does not matter.  Bravo, Sec. Wos, but, please follow through.

The fact of the matter is if Sec. Wos wants to “reduce the burden on hospital ERs and law enforcement” AND truly provide Medicaid recipients with mental health/substance abuse issues, Sec. Wos will have to take on the MCOs head-on.  Grab the bull by the horns.  Pony-up.  Put your big, boy pants on.  Just do it! (Nike). Buck up…against the MCOs. The Goliaths will have to be defeated.

Why?

Here a  little secret:  The MCOs have monetary incentive to deny medically necessary mental health services….WHAT???? Shut the front door!!!

Let me explain:

The managed care organizations (MCOs) in NC are managing behavioral health care services for Medicaid recipients.  However, the MCOs are pre-paid.  What does that matter?  It’s all about the money.

For example, a Medicaid recipient suffers schizophrenia with auditory and visual hallucinations.  (We will call him Bill).  Bill’s psychiatrist, after an assessment, requests assertive community treatment team services (ACTT), which is an extremely high-level mental health service (and very expensive).  The MCO denies ACTT services based on “failing to exhaust lesser intensive services” (which is NOT a criterion for entrance criteria, but DHHS is not supervising or managing the MCOs, so who cares whether the MCOs follow DHHS policy).  Bill becomes incarcerated.  Yes, it is more expensive for tax payers to pay for Bill’s incarceration versus the community based services requested, but it is cheaper for the MCO.  The MCO does not pay the prison for Bill’s room and food; tax payers do.  The MCO is successful in keeping its money.  Similarly, Bill becomes hospitalized.  The hospital admits Bill into Butner or Holly Hill.  Sure it is more expensive for tax payers to pay for Bill’s stay at Butner or Holly Hill, but it is cheaper for the MCO.  The MCO does not pay Butner or Holly Hill; the tax payers do.  The MCO is successful in keeping its money.

But, according to the Press Release from DHHS, Sec. Wos wants to stop the MCOs from pushing the mentally ill to prisons and emergency rooms.  But in order to stop the MCOs, she will have to stop the Goliaths (MCOs).

Interestingly, everyone always thinks of David as the underdog to Goliath and, therefore, is surprised/excited when David beats Goliath.  In reality, according to “David and Goliath: Underdogs, Misfits, and the Art of Battling Giants,” a book by Malcolm Gladwell, David was not the underdog.  According to Gladwell, Goliath suffered from acromegaly or, more commonly known as, gigantism, which can cause people to grow to abnormal heights. People who suffer from acromegaly, usually, also suffer other symptoms, such as poor eyesight and mobility.  Yes, Goliath looked scary and big, but, in reality, he may have been slow and somewhat blind.  Remember his words to David?  “Come to me so that I may feed your body to the birds of the air…”  “Come to me.”  As in, I cannot see you yet.  Come closer.

Furthermore, David was a trained “slinger.”  As in, the person in battle back then who did not wear armor and who became skilled at slinging rocks at high speeds to kill opponents.  Imagine a major league baseball player with a fast ball of 100mph throwing the ball directly at your head.  David was a shepherd, and he became a master with the sling to kill the wild life attacking his sheep.  Back in biblical times, being large, massive and heavily armored against a master slinger would be like bringing a butter knife to a gun fight.  Goliath had no chance.  David was smart.  Sec. Wos will need to be smart too, maybe even a master slinger.

A portion of the DHHS press release reads, “As a part of this initiative, a Crisis Solutions Coalition will be created to address the inefficiencies that currently exist surrounding crisis services in the state. Secretary Wos has charged Dave Richard, director of the DHHS Division of Mental Health, Developmental Disability and Substance Abuse Services, with leading this coalition. Patient advocates, along with leaders from healthcare, government, and law enforcement communities will be invited to join the coalition to help:

  • Recommend and establish community partnerships to strengthen the continuum of care for mental health and substance abuse services.
  • Promote education and awareness of alternative community resources to the use of emergency departments.
  • Make recommendations related to data sharing to help identify who, when and where people in crisis are served, and what the results of those services are.
  • Create a repository of evidence-based practices and provide technical assistance to Local Management Entities/Managed Care Organizations (LME/MCOs), law enforcement and providers on how to respond to crisis scenarios.
  • Recommend legislative, policy and funding changes to help break down barriers associated with accessing care.
  • Assist with the creation of LME-MCO Local Business Plans to provide a road map for mental health investments in the community.”

Hospitals are ecstatic and they should be!  “I want to thank Governor McCrory, Secretary Wos and the Department of Health and Human Services for their commitment to this issue,” said Dr. Bill Roper, CEO of UNC Health Care. “We look forward to partnering with you and the community to solve the mental health problems facing our state.”

The prisons should be ecstatic too.

Herein lies the problem…the MCOs are, most likely, NOT ecstatic.  Sec. Wos, by announcing this crisis solution, has placed her hand in the MCOs’ cookie jars.

Goliath will challenge David. “Come to me.”

Can you imagine the backlash by the MCOs if Sec. Wos actually followed through with this crisis solutions? In order to follow through with the crisis solutions, Sec. Wos will have to force the MCOs to authorize medically necessary mental health care services.  With more services authorized, there will be a greater need for providers who accept Medicaid; thus reducing the number of terminations of provider’s Medicaid contracts.

Because if Sec. Wos wants, as she stated in the Press Release, to stop the revolving doors at the hospitals for the mentally ill, Sec. Wos has to take on the MCOs.  DHHS will have to do its job and supervise/manage the MCOs.

But can David be smart enough? Or will the Goliaths prevail?

“Come to me.”