Category Archives: Community Support Team
A Story of Three Medicaid Providers’ Erroneous Terminations
I have a story for you today that affected three, Medicaid, behavioral health care providers back in 2013. Instead of me spouting off legal jargon that no one understands, I am going to tell you a nonfictional story.
Since both stories occurred in NC, we will use DHHS, the Department of Health and Human Services, which is the acronym for NC’s Medicaid agency.
In 2013, a Residential Level IV facility was shut down overnight by the managed care organization (“MCO”), Alliance, which was one of many MCOs that managed all behavioral health care for NC Medicaid recipients within their respective, catchment areas. The facility, we will call Alpha, housed 5-6, at-risk, teenage, African American, males, who could not reside in their family’s home due to mental illness, substance abuse, legal trouble, and/or violence. The owners of Alpha, themselves were large, muscular, African American males, which, I can only imagine, was to their benefit.
Alliance terminated Alpha from its catchment area, but since Alpha only provided Medicaid services in Alliance’s catchment area, Alliance’s decision would close a business immediately, terminate all staff, cause the owners to lose their careers, and the residents would have no home.
Alpha hired me. We were successful in obtaining an injunction. Click on “injunction” to read my blog about this exact situation in 2013, written by me in 2013. I have written numerous blogs on the topic of erroneous terminations of Medicaid providers over the years. Here are a couple: blog and blog.
An Administrative Law Judge (“ALJ”) ruled in our favor that Alliance does not have the legal authority to terminate a provider for no reason or any erroneous reason. The ALJ Stayed the termination and Ordered Alliance to reverse the termination and continue to contract with Alpha.
Whew! We thought. Then, Alliance flat-out ignored the ALJ’s Order.
We brought a Motion for Contempt and/or Sanctions; however, we were instructed, at the time, that a Writ of Mandamus was the appropriate venue in Superior Court. This too was unsuccessful.
During our legal battle for Alpha, we were successful in obtaining injunctions for two other provider also terminated without cause.
Alpha did close. But the bright side of the story is what happened in the future. Those 3 injunctions, which were ignored by MCOs to the detriment of the three providers, were the last ones to be ignored. In the years that followed, OAH ALJs routinely held MCOs accountable for erroneous terminations and without cause terminations.
My team has witnessed successful injunctions across the country that protect providers from arbitrary and capricious terminations. We have litigated many of these successful injunctions.
An Ominous Cloud Looms Over NC’s Mental Health System! And Radix Malorum Est Cupiditas!
“There is an ominous cloud over North Carolina’s mental health care system that many fear is limiting access to care and treatment by those who need it the most,” wrote Jason deBruyn in Friday’s Triangle Business Journal article titled, “Mental Health Block.”
(Thanks, Jason, for the nice spread:) )
Two phrases that can never be good when linked together: “an ominous cloud” and “mental health care system.” Upon reading “ominous cloud,” I get this dark (dare I say ominous?), dreary outlook on whatever the “ominous cloud” is over. Then to discover that the “ominous cloud” is over our mental health system here in NC, I get goosebumps and a pit in my stomach (and a bit of disgust at the sheer ineptness of the Department of Health and Human Services (DHHS)).
What is causing that “ominous cloud” over our mental health system? Well, according to Jason, the managed care organizations (MCOs) that were implemented across the state only this past year.
What are these MCOs you talk of?
The MCOs were established to manage the Medicaid mental health, developmentally disabled, and substance abuse services in NC. If you want mental health services or are attempting to get prior authorization on behalf of a Medicaid recipient, then the buck stops with the MCO. See my blog: “NC MCOs: The Judge, Jury and Executioner.” Or “NC MCOs: Accountability Must Be Somewhere!”
Here is a list of the MCOs along with the “correct toll free number” in case you wanted it:
| LME-MCO | CORRECT TOLL FREE NUMBER |
| Alliance Behavioral Health | 1-800-510-9132 |
| Cardinal Innovations Healthcare Solutions | 1-800-939-5911 |
| CenterPoint Human Services | 1-888-581-9988 |
| CoastalCare | 1-855-250-1539 |
| East Carolina Behavioral Health (ECBH) | 1-877-685-2415 |
| EastPointe | 1-800-513-4002 |
| MeckLINK | 1-877-700-3001 |
| Partners Behavioral Health Management | 1-888-235-4673 |
| Sandhills Center | 1-800-256-2452 |
| Smoky Mountain Center | 1-800-849-6127 |
| Western Highlands Network | 1-800-951-3792 |
Going back to the “ominous cloud…”
Jason writes further that “under the state’s new payment system, MCOs have the unbridled authority to terminate providers in an attempt to keep costs down – with little accountability for the process.”
The only word I would change is “little” to “no.” But, then, maybe Jason was referring to the little accountability as arising from advocates such as myself who are fighting for the providers.
Have I not been saying this all along? The MCOs can terminate providers with little (or no) accountability!! To save money!!
And who suffers?? The providers, yes. And the Medicaid recipients!! “Patients aren’t going to know where to go to access services,” Goldston says. “Those patients are going to suffer.”
Why? Why are these MCOs terminating providers and denying services to our most-needy population?? Have they no heart? No conscience?
One word answers all these questions:
Money
Radix malorum est cupiditas, meaning, in Latin, greed is the root of all evil. In the Bible, 1 Timothy 6:10, starts “For the love of money is the root of all kinds of evil…”
“MCOs register as not-for-profit organizations and receive fixed amounts of money from the state, called their “capitation.” Unlike physical health care providers, when Medicaid patients receive mental health services, their providers bill these MCOs instead of the N.C. Department of Health and Human Services. If an MCO doesn’t spend up to its capitation level, it keeps the remainder. And therein lies the problem, say provider advocates,” writes Jason. (emphasis added).
And he is absolutely correct!
What was the MCOs’ response?
“The myth that we are trying to eliminate every provider in our network is not an accurate statement,” says Rob Robinson, chief operating officer for Alliance Behavioral Healthcare, the MCO that covers Wake, Durham, Johnston and Cumberland counties.
Mr. Robinson’s comment, however, is incorrect on, at least, two fronts: (1) the “myth” is not that the MCOs are trying to eliminate every provider; and (2) it is no myth. The MCOs are, without question, terminating as many providers from the networks as possible without the appearance that services will not get rendered. The MCOs need a certain number…just to appear that services are not getting cut.
So what is that magic number?
A client informed me a couple of months ago that Smokey Mountain Center (SMC) told him that SMC wants two providers per service per county. If correct, hundreds and hundreds of providers will be put out of business. And, hello…I thought the current Republican administration was pro small business!
Alliance has chopped its provider network recently.
Just recently, Alliance called for Requests for Proposals (RFPs) from all contracted providers within its catchment area. Kinda like a tryout. When I was in college at NCSU, I was on the cheerleading team. I will never forget being a freshman and learning these routines that I would have to perform in front of a judge’s panel. Literally hundreds of young men and women were all learning the same routine…all to perform for the tryouts. In the middle of learning the routine with hundreds of people, I looked around and realized that only 8 girls and 8 guys would be chosen. Which meant 90% of the people there would not be on the team. I tried to remove the thought from my head.
When the D-Day arrived, there was simply a white piece of paper taped to the gymnasium’s window on the outside for anyone to see. I had to walk up to the piece of paper, shuffle through the small crowd surrounding it, ignore others’ tears and congratulations, and look for my name.
Holding my breath, I searched for “Knicole Carson” (my maiden name). And I did not see it. For a moment, I was crushed. Then I saw “Nicole Carson.” My name was on there, just misspelled.
What does college cheerleading tryouts have to do with NC Medicaid?
Alliance’s RFPs created a provider tryout. Hundreds submitted. Only a few were chosen. Those few chosen were written on a piece of paper for all to see, and providers had to scan the list to see if they were chosen.
For Wake county, Alliance decided to award a 1 year contract for community support team (CST) to only 6 companies. For the entire county of Wake, Alliance has determined that only 6 companies may provide CST to Medicaid recipients (with a 1 year contract). Only 6 names were on the list.
For Durham county, Alliance decided to award a 1 year contract for CST to only 5 companies. For the entire county of Durham, Alliance has determined that only 5 companies may provide CST (with a 1 year contract). Only 5 names were on the list.
Now let’s go back to Mr. Robinson’s comment:
“The myth that we are trying to eliminate every provider in our network is not an accurate statement,” says Rob Robinson, chief operating officer for Alliance Behavioral Healthcare, the MCO that covers Wake, Durham, Johnston and Cumberland counties.
You are right, Mr. Robinson, you aren’t trying to eliminate “every provider.” Just the ones that Alliance, in its subjective discretion, doesn’t want to deal with (I don’t care that I ended the sentence in a preposition).
Oh, and what about our State Plan?
Our State of North Carolina MH/DD/SA Health Plan Renewal, states, in pertinent part, as an answer regarding concerns as to provider choice with MCOs, “network capacity studies and gap analyses were conducted by Cardinal Innovations Healthcare Solutions (CIHS) annually and prior to expansion the coverage area, and by the new PIHPs prior to start-up, as required. Access and provider choice appear to be as good as or better than it was prior to waiver implementation, although there is room for improvement in several areas.” (emphasis added).
Obviously, that was written a while ago and Cardinal, an MCO, was the entity conducting the study (cough, cough…bias…cough). Regardless, we told the federal government that “provider choice appears to be as good or better than it was prior implementation.” Are you kidding me???
How many providers didn’t make Alliance’s cut?
How many providers have MeckLINK terminated? Smokey Mountain?
Jason deBruyn was dead on when he said, “There is an ominous cloud over North Carolina’s mental health care system that many fear is limiting access to care and treatment by those who need it the most.”
Tip #4: How to Avoid Medicaid Recoupment
The State contracted with PCG (a consulting group) to review Medicaid payouts to health care providers providing community support, community support team, and personal care services to Medicaid recipients in 2010. The health care provider receives a letter called “The Tentative Notice of Overpayment,” which states the amount owed to the State. Frequently, the amounts are in the hundreds of thousands of dollars.
The tip today is: Remember to read all the Implementation Updates and Medicaid manuals from the time period which is at issue. The rules and regulations have changed drastically over the years. For example, if the Notice of Overpayment covers January 2010 through June 2010, the 2012 rules will not apply.
An example in which reading all the pertinent Implementation Updates for the relevant time is as follows:
PCG tells Health Care Provider ABC (“ABC”) that ABC must pay back $450,000 for Medicaid services provided to Medicaid recipients for community support team services in January through June 2010. 90% of PCG’s alleged document deficiencies found is due to the Person Centered Plan (“PCP”) being signed prior to the comprehensive assessment. Obviously, Medicaid rules state that the assessment must occur prior to any PCP.
However, NOT in 2010! In early 2010, DHHS drafted Implementation #68, which stated that health care providers would no longer use an Introductory PCP. Remember those? An Introductory PCP was drafted prior to the assessment. An Intro PCP was extremely basic and really just gave little information regarding contacts and a brief overview of the Medicaid recipeints’ issues. But, importantly, the Intro PCP was signed prior to the assessment, unlike now.
So when PCG cited these 90% of errors because ABC’s documentation was misdate; and, therefore ABC must return Medicaid monies, PCG failed to read Implementation Update #68. Back in 2010, a PCP could be signed prior to an assessment (an Intro PCP). So, actually, all the “errors” were not errors. And ABC was saved from owing $450,000 to the State.
The morale? READ THE IMPLEMENTATION UPDATES FROM THE RELEVANT TIME PERIOD!!!
