Category Archives: CABHA
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.
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.
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!
Planning for the inevitable is smart. And it is inevitable if you are a provider and you accept Medicaid that you will undergo some sort of review, whether it is onsite or database checks, in the near future. And only two outcomes can result from this upcoming review:
Are YOU ready for that test???
So, it is imperative to arm yourself with knowledge of your rights, a liability insurance policy that covers attorneys’ fees (and lets you pick your attorney), and confidence that your billing practices comply with rules and regulations. If you do not know whether your billing practices comply, do a self-audit or hire a knowledgeable billing expert to audit you.
Read or not here they come…
Beginning June 9, 2014, Public Consulting Group (PCG) began scheduling post-enrollment site visits to fulfill federal regulations 42 CFR 455.410 and 455.450, which require all participating providers to be screened according to their categorical risk level: high, moderate, or limited.
What does being high, moderate, or limited risk mean?
If you are limited risk, the state will check your licenses, ensure that you, as a provider, meet criteria for applicable federal and state statutes, conduct license verifications, and conduct database checks on a pre- and post-enrollment basis to ensure that providers continue to meet the enrollment criteria for their provider type. This is the only category that does not need an onsite review.
If you are moderate risk, the state does everything for you as if you are a limited risk plus perform on-site reviews. (Enter PCG).
If you are high risk, the state will perform all reviews as if you are a moderate risk but also will conduct a criminal background check, and require the submission of a set of fingerprints in accordance with §455.434. (And you thought fingerprints for only for the accused.)
Let’s discuss in which level risk you fall. NC Gen. Stat §108C-3 spells out the risk levels. Are you a new personal care service (PCS) provider getting ready to start your own business? You are high risk. Are you a directly-enrolled behavioral health care provider rendering outpatient behavioral health care services? You are high risk. Do you provide HIV Management services? You are high risk.
Here is a list of high risk providers:
- Prospective (newly enrolling) adult care homes delivering Medicaid-reimbursed services.
- Agencies providing behavioral health services, excluding Critical Access Behavioral Health Agencies
- Directly enrolled outpatient behavioral health services providers.
- Prospective (newly enrolling) agencies providing durable medical equipment, including, but not limited to, orthotics and prosthetics.
- Agencies providing HIV case management.
- Prospective (newly enrolling) agencies providing home or community-based services pursuant to waivers authorized by the federal Centers for Medicare and Medicaid Services under 42 U.S.C. § 1396n(c).
- Prospective (newly enrolling) agencies providing personal care services or in-home care services.
- Prospective (newly enrolling) agencies providing private duty nursing, home health, or home infusion.
- Providers against whom the Department has imposed a payment suspension based upon a credible allegation of fraud in accordance with 42 C.F.R. § 455.23 within the previous 12-month period. The Department shall return the provider to its original risk category not later than 12 months after the cessation of the payment suspension.
- Providers that were excluded, or whose owners, operators, or managing employees were excluded, by the U.S. Department of Health and Human Services Office of Inspector General or another state’s Medicaid program within the previous 10 years.
- Providers who have incurred a Medicaid or Health Choice final overpayment, assessment, or fine to the Department in excess of twenty percent (20%) of the provider’s payments received from Medicaid and Health Choice in the previous 12-month period. The Department shall return the provider to its original risk category not later than 12 months after the completion of the provider’s repayment of the final overpayment, assessment, or fine.
- Providers whose owners, operators, or managing employees were convicted of a disqualifying offense pursuant to G.S. 108C-4 but were granted an exemption by the Department within the previous 10 years.
Here is a list of moderate risk providers:
- Ambulance services.
- Comprehensive outpatient rehabilitation facilities
- Critical Access Behavioral Health Agencies.
- Hospice organizations
- Independent clinical laboratories.
- Independent diagnostic testing facilities.
- Pharmacy Services.
- Physical therapists enrolling as individuals or as group practices.
- Revalidating adult care homes delivering Medicaid-reimbursed services.
- Revalidating agencies providing durable medical equipment, including, but not limited to, orthotics and prosthetics
- Revalidating agencies providing home or community-based services pursuant to waivers authorized by the federal Centers for Medicare and Medicaid Services under 42 U.S.C. § 1396n(c).
- Revalidating agencies providing private duty nursing, home health, personal care services or in-home care services, or home infusion.
- Nonemergency medical transportation.
Here are the limited risk providers:
- Ambulatory surgical centers.
- End-stage renal disease facilities.
- Federally qualified health centers.
- Health programs operated by an Indian Health Program (as defined in section 4(12) of the Indian Health Care Improvement Act) or an urban Indian organization (as defined in section 4(29) of the Indian Health Care Improvement Act) that receives funding from the Indian Health Service pursuant to Title V of the Indian Health Care Improvement Act.
- Histocompatibility laboratories.
- Hospitals, including critical access hospitals, Department of Veterans Affairs Hospitals, and other State or federally owned hospital facilities
- Local Education Agencies.
- Mammography screening centers.
- Mass immunization roster billers.
- Nursing facilities, including Intermediate Care Facilities for the Mentally Retarded.
- Organ procurement organizations.
- Physician or nonphysician practitioners (including nurse practitioners, CRNAs, physician assistants, physician extenders, occupational therapists, speech/language pathologists, chiropractors, and audiologists), optometrists, dentists and orthodontists, and medical groups
According to the June 2014 Medicaid Bulletin, the onsite reviews will last approximately two hours and PCG will send 2 representatives to conduct the review.
How to prepare for the onSite reviews
- Read and learn. (or re-learn, whichever the case may be).
“Providers will be expected to demonstrate a working knowledge of N.C. Medicaid through responses to a series of questions.” See June 2014 Medicaid Bulletin.
Knowledge is power. Brush up on your applicable DMA Clinical Coverage Policy. Review the NC Medicaid Billing Guide. Re-read your provider participation agreement. If you don’t understand a section, go to your attorney and ask for an explanation. Actually read the pertinent federal and state statutes quoted in your participation agreements because, whether you know what the laws say or not, you signed that agreement and you will be held to the standards spelled out in the federal and state statutes.
- Call your liability insurance.
Be proactive. Contact your liability insurance agent before you get the notice of an onsite review from PCG. Have a frank, open discussion about these upcoming onsite reviews. Explain that you want to know whether you policy covers attorneys’ fees and whether you can choose your attorney. If your policy does not cover attorneys’ fees or does not allow you to choose your own lawyer, beef up your liability insurance plan to include both. Believe me, the premiums will be cheaper than an attorney from your own pocket.
- Be confident.
Presentation matters. If you whisper and cower before the PCG reviewers, you will come across as weak and/or trying to hide something. Be polite and forthcoming, but provide the information that is asked of you; do not supply more information than the reviewers do not request.
I always tell my clients before their deposition or a cross examination by the other side, “Answer the question that is asked. No more. If you are asked if your favorite color is blue, and you favorite color is red, the correct response is “No,” not “No, my favorite color is red.” Do not over-answer.
If you do not believe that you can be confident, ask your attorney to be present. I had someone tell me one time that he did not want an attorney present because he felt that the auditors would think he was hiding something and he did not want to appear litigious. I say, this is your company, your career, and your life. If you need the support of an attorney, get one. Whenever I give this advice, I try to imagine that I am telling the same advice to my mother. My mother, bless her heart, does not have the confidence to stand her ground in high pressure situations. She would rather yield her position than be the least bit confrontational. If that also describes you, have your attorney present.
- Know your rights.
What if you fail the onsite review? Can you appeal? You need to know your rights. When you get a notice from PCG that an onsite review is scheduled, contact your attorney. Make sure that BEFORE the onsite review, you understand all the possible consequences. Knowing your rights will also help with #3, confidence. If you know the worst case scenario, then you stop creating worse case scenarios in your mind and become more confident.
Ready or not, the PCG reviews are coming, so get ready!