Category Archives: Community Support Team
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.
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!!!