Category Archives: Outpatient Behavioral Health

CCME’s Erroneous Denials: DMA’s Attempt to Explain

For months health care providers in North Carolina that accept Medicaid and that are undergoing cumbersome audits by the state have been asking, “Why are these claims being denied?” and “Show me in the DMA Policy where my documets are noncompliant.”

Finally, in North Carolina Division of Medical Assistance’s (DMA) March 2013 Medicaid Bulletin, DMA (long overdue) attempts to analyze information from the Carolina Centers of Medical Excellence (CCME) and to provide health care providers with concrete examples of documentation errors that have caused CCME to deny claims.  Good job, DMA. Since CCME was awarded the contract to conduct the prepayment reviews back in 2009,  we are so excited to see concrete feedback now in 2013.

So a little late, but the information is there, right? WRONG.

From my experience as an attorney for health care providers undergoing these prepayment reviews, the documentation errors listed in the March 2013 Medicaid Bulletin are misleading, incorrect, only partially explanatory, and outright wrong.

To read the entire March 2013 Medicaid Bulletin click here.

According to the March 2013 Medicaid Bulletin: these are the trends of documentation errors identified: (For the sake of time (my time) I will only discuss PCS, but the problems in PCS are ever-prevalent in other services. The March 2013 Medicaid Bulletin lists “trends” for Durable Medical, CAP, and outpatient speech, as well. But I will need to devote future blogs to each topic.)

The March 2013 Bulletin reads, in part,:

To date, the following trends have been identified:

Personal Care Services/In-Home Care (PCS/IHC):

  • Providers and their staff were not qualified to supply the services billed;
  • Examples include inappropriate levels of certification, lack of policy-required background checks and failure to meeting staff training requirements, among other things;
  • Lack of service documentation, for example missing signatures;
  • Plan of care was not followed and any deviation from the Plan of Care was not documented;
  • Supervision was not conducted per clinical policy requirements.

(The Bulletin continues past this, but I will concentrate on PCS/IHC).

Let’s analyze each “trend:”

1.  Providers and their staff were not qualified to supply the services billed.  The below picture  depicts aan actuual ddenial from CCME.  Staff qualifications is reason Q11.


In the picture above, read “reason for denial” Q11. That is the complete explanation provided by CCME for denying a claim because of “unqualified” staff.

CCME does not provide the provider with the name of the questionable staff member.  No information as to what exactly is missing. No explanation as to how the documentation does not support the staff is qualified. Nothing. The provider is left guessing and perplexed because, in actuality, CCME is in possession of the qualifications of all staff.

It is important to note that, at the outset, at the very beginning of the audit, the provider is required to supply CCME the qualifications for every single staff member employed by the provider who is serving the Medicaid recipients.  Therefore, CCME has in its possession all qualifications of all staff throughout the process.

In the above denial, the staff member who provided the services was completely qualified to provide the services.  The staff member met all criteria.  However, in this case, CCME was unable to decipher the staff member’s signature.  Instead of contacting the health care provider and asking which staff member’s signature was on the document, CCME merely denied the claim.  I mean, isn’t it easier to deny the claim than pick up the phone to determine if, in fact, the staff member was actually qualified?

Next example:

2.  Examples include inappropriate levels of certification, lack of policy-required background checks and failure to meeting staff training requirements, among other things;

This is actually not a different reason from #1.  This is DMA trying to give examples of #1, although, again, see above for the reality.

Next example:

3.  Lack of service documentation, for example missing signatures;

This may be my favorite example that DMA gives as a reason for denial. Because, of course, if a service note is not signed, the service note is invalid.  However, CCME does not give “lack of signature” as a reason for the denial. Instead, ithe denial looks like this:


See Q5: No valid treatment plan/PCP in place for the date of the service billed.  The denial for a service note is identical; there is no valid service note for the date of service billed.

There is zero explanation as to why the service note is invalid. Was there a service note at all? Was the service note misdated? Not signed? Not dated?  Zero explanation.

In the denial above, an authorization was actually in place for the date of service and the provider submitted a valid treatment plan. Yet CCME still denied the claim. Why? Well, I cannot pretend to understand the thoughts behind this denial, but I was told by a CCME representative that the authorization was not in place for the particular date of service at issue here, but, in this, case, no authorization was required as the service rendered on this date of service was within the client’s first 16 unmanaged visits for Outpatient Behavioral Therapy (OBT), as the client was a child.  Apparently CCME missed that portion in Clinical Policy 8C.

As for the treatment plan, in this case, CCME stated the treatment plan was invalid because the provider had not hand signed the treatment plan.  This provider, per DMA’s electronic signature policy, had complied wth all requirements in order to electronically sign all documents.  However, apparently CCCME failed to review the electronic signature policy.  Because, erroneously, this claim was denied.

Next example:

4.  Plan of care was not followed and any deviation from the Plan of Care was not documented.


Read reasons for denial Q8, Q10, and Q 12.  When I first read this explanation by DMA as to why CCME is denying claims, I said, “Huh?”  But then I thought back to the reconsideration reviews and hearing with CCME representatives that I have had.  In my experience, CCME reps have read service notes, the goals on service notes, and told me that the goals on the service notes did not reflect the goals in the PCP or treatment plan.  Whereas, when I read the PCPs or treatment plans, I subjectively read the goals on the service notes as absolutely encompassing the goals written on the PCPs or treatment plans.  Let me be clear: Whether a Plan of Care was or was not followed (per the service note) is a subjective decision. Where I may believe that the plan of care was absolutely followed, someone else may disagree.  (My opinion on CCME being allowed to make subjective opinions in this very important audit process will have to be the subject of another blog). Nonetheless, for DMA to state that there have been findings of plans of care not being followed when I have found that, in reality, the CCME denials are subjective, and, in many cases wrong, I find DMA’s examples of issues found misleading.

In the case in which the above denial was at issue, (for the sake of brevity, I will only review the denials at issue in this blog, but every one of these denials were erroneous)

  • Q8: Documentation does not reflect clients’ response to therapy: Here, the service note (which to preserve attorney/client privilege I will summarize with no names) stated, “Jimmy showed positive signals when we explained that his mother would be more involved.  He expressed concern, but we talked about the possible outcomes. He left saying that he would work hard on the homework he was given.”  If that service note does not reflect the client’s response to  therapy, then someone needs to explain to me what detail is needed for a service note to reflect a client’s response.  Perhaps, CCME expects War and Peace.  Perhaps CCME expects details such as, Jimmy pursed his brow and rubbed his head when we discussed his mother.  Jimmy said, “My response to this therapy is that I do not want to speak to my mother.” Perhaps, the service note should have had a section bolded: “Jimmy’s response to therapy.” Perhaps that would be easier.
  • Q10: Service note does not reflect the specific treatment goal in the treatment plan/PCP: In this case, the PCP enumerated 3 goals.  One was stated as (summarized to protect attorney/client privilege), “Jimmy will control his aggression with authority figures, particularly his mother.”  The service note’s goal stated that “Jimmy will become more involved with his mother and remember that his mother is in charge.”  In my opinion, the service note goal is directly in-line with the PCP goal.  But, again, this is a subjective determination that has been placed in the hands of CCME.
  • Q12: Interventions provided are not individualized in order to meet the recipient’s diagnosis, clinical, and intellectual needs: What? How are mental health services rendered for a particular client, not individualized? Jimmy has issues with authority.  Did the provider talk about financial issues? THAT would be not individualized.

Regardless, the reasons for denial that are  issued by CCME (the reasons in the pictures) are completely different from the reasons for denials stated by DMA in March 2013 Medicaid Bulletin.  It seems the Medicaid Bulletin’s reasons for denial are more concrete and understandable.  Then why can CCME not provide better, more concrete and understandable reasons?

Instead, CCME is denying claims because the CCME rep cannot read the staff signature, instead of asking for the identity of the staff member.

At my last hearing in which a CCME rep testified, the CCME rep testified that if there is ever a question, a grey area, CCME errs in the favor of the provider.  Call me cynical, I don’t believe it.

NC Medicaid Provider Terminated Arbitrarily and Without Cause

Friday evening WRAL covered my Preliminary Injunction hearing at the Office of Administrative Hearings (OAH).

Please watch:


Termination of a Provider’s Medicaid Contract May Result in Homeless, Mentally Ill Adolescents

A client came to me, we will call him John, and explained that his company X had been placed on prepayment review by the Carolinas Center of Medical Excellence (CCME) 6 months prior.  Like every other health care provider that is placed on prepayment review, he thought… “That’s fine. My documents comply with all applicable Medicaid rules and regulations….This will be easy greasey.”

6 months later, he is sitting in my office with a Notice of Termination of Company X’s Medicaid contract.

CCME had audited Company X’s Outpatient Behavorial Therapy (OBT) services, found the documentation noncompliant and terminated the Medicaid contract.

Problem is, Company X does not only provide OBT.  Company X runs residential services for children and adults (mostly adolescents) with severe mental illnesses. Meaning, Company X provides these children and adults with a home, 24-hour care, food, essentials, and therapy.

The residential services were not found out of compliance.  Only the OBT.  I asked John what the percentage of OBT services Company X providers compared to the residential, and he said that OBT was a very small percentage.  OBT is the daytime therapy for the all the residents of Company X.

I asked him what would happen if the Notice of Termination of Medicaid contract went into effect.

“I would have to close my doors.”

Me: “What would happen to your clients?”

“Some would go back to the families that couldn’t care for them initially. Others, I don’t know. All the residential providers that I know of around us have gone under for whatever reason.”

Me: (In shock): “They would be homeless?”

“Many, yes.”

Folks, do not freak out yet. We  have filed a Temporary Restraining Order (TRO) and Preliminary Injunction against the Department of Health and Human Services (DHHS) disallowing DHHS from terminating the Medicaid contract of Company X until a full hearing can be heard.  The TRO was granted.  Our hearing to plead our case for the Preliminary Injunction is tomorrow.

Will keep you posted.


Final Agency Decision No Longer Needed in Medicaid Appeals

This is huge!! Not often in Medicaid administrative law, does the appeal process actually change.  But the appeal process has changed.

In the past, to appeal a decision from North Carolina Department of Health and Human Services (DHHS), you had to file a Petition for Contested Case. The Petition would be heard by an Administrative Law Judge (ALJ) at the Office of Administrative Hearings (OAH).

Once the ALJ rendered a Decision, DHHS would review the ALJ Decision and render a “Final Agency Decision.” Since DHHS is the entity rendering the Final Agency Decision, 9 times out of 10, the Final Agency Decision happened to decide in favor of the Department.

To appeal a Final Agency Decision, you had to request a Judicial Review in Superior Court.  For the Judicial Review,  the Superior Court sits as a Court of Appeals.  Meaning no additional testimony or evidence may be introduced, but each side arguments the legal arguments with the evidence already introduced at OAH.

Not anymore. For dental, behavioral health, and medical authorizations, following an OAH Decision, no Final Agency Decision will be rendered.

This means that any decision made by OAH is the decision that the provider and beneficiary can act upon and that a final agency decision by DHHS is no longer required. 

OAH will mail a copy of the decision via trackable mail (e.g., certified mail, registered mail, USPS trackable mail) to the parties identified on the appeal request form.

How the OAH decision is implemented depends on whether the Decision agreed with DHHS (or the contracting company) or overturned DHHS, in full or in part.  The implementation language is no important, I copied and pasted the language from the

See below:

An OAH decision that upholds the agency action will be implemented no later than three business days from the date the OAH hearing decision is mailed.

Decisions that Reverse the Agency Action (Utilization Review [UR] Contractor Decision) in Part or in Full

  • If the OAH decision or a mediated settlement holds that all or part of the requested services were medically necessary, payment for those services as approved in the OAH decision or settlement will be authorized by Medicaid or its UR contractor within three business days of receipt of the decision. This authorization will remain in effect for 20 prospective calendar days after the date of the decision.
  • If the provider believes that it is medically necessary for the beneficiary to continue the service that has been under appeal, the provider shall submit a prior approval request to the appropriate UR contractor within 15 calendar days of the date of the OAH decision in order to avoid an interruption in services. Upon receipt by the UR contractor of a request for service authorization within the 15 calendar days of the OAH decision, a determination to approve, deny, reduce, or terminate the request will be made within 15 business days – or in accordance with the contractor’s contract with Medicaid. If the request cannot be approved as submitted, authorization for payment will remain in effect without interruption for at least 10 calendar days following the mailing of the notice of decision on the new request for prior approval.
  • If the request is denied or reduced, it will be treated as a timely request for reauthorization and maintenance of service (MOS) pending appeal will apply.

Remember, regardless of the OAH Decision, you still have the right to a judicial review at Superior Court.


The State Medicaid Auditors Who Cried, “Fraud!”

Similarly to the “Boy Who Cried Wolf” from Aesop’s fables, The state Medicaid auditors are crying, “Fraud.”

Remember in Aesop’s fables, the boy repeatedly cried, “Wolf.”  Each time the villagers ran to help the  boy, only to find the boy laughing at the villagers’ naivety.  After numerous “fakes,” a wolf truly came to hunt the boy’s sheep.  While he feverishly cried, “Wolf” at the top of his lungs, the villagers were nowhere to be found.

Now it seems that the state’s Recovery Audit Contractors (RAC) are mimicking the actions of the boy who cried wolf. How do I make this literary analogy between the boy who cried wolf and the RAC’s actions? Because the purpose of the RACs were to detect fraud.  The federal government required all states to implement a state-wide RAC program to detect fraud, not innocent paperwork mistakes.

Fraud is defined as: an intentional deception made for personal gain or to damage another individual.

If you saw WRAL 6:00 news Friday, then you saw one of my clients who had been placed on prepayment review. What a horror story!! My client noticed last August (2012) that the State stopped paying her Medicaid reimbursements. Now six months later she received a notice that her Medicaid contract was being terminated.  The reasons were unclear, but the statute  under which the State may, first, place a health care provider on prepayment review, and, subsequently, terminating the health care provider’s Medicaid contract was drafted to detect Medicaid fraud.

However, my client did not commit fraud. All the mental health services for which she was paid, were actually rendered for Medicaid recipients.  The alleged problems? Innocent paperwork errors, or, in some instances, errors on the part of the RACs.

For example, DMA Clinical Policy 8C requires the service notes to indicate the duration of the service.  However, for most of the Outpatient Behavioral Health services, the CPT code, by definition, states the duration.  If a provider bills for 90816: the services was 20-30 minutes.  Therefore, by the provider writing the CPT code, the provider stated the duration of the service.  Yet, the RACs are citing lack of duration written on the service notes, despite the CPT codes providing the duration.

Why? Why would the RACs proceed to audit Medicaid claims crying “Fraud” for these innocent paperwork errors, or in the case of the lack of duration of services, not even errors on the part of the provider?

Good question. I do not have the answers.  However, I have theories:

1.  Lack of Supervision/Confusion:  The RACs have these government contracts to audit  Medicaid payments, but the state is not supervising the audits.  Basically, the state created these RACs and then turned them loose. The lack of supervision by the state is creating a free-for-all.  The RACs are trying to do the jobs for which they were hired, but without guidance.

2.  Incentive:  Interestingly, RACs  are reimbursed by a contingent fee. Meaning, if the contracted companies recover more money from the health care providers, the contracted company received a higher reimbursement.

Now because the contracted companies are paid more if they recover more, does that create a bias? A perceived bias? Certainly a desire by the contracted companies’ employees to recover more Medicaid money; after all, the employees are only human.

Since these RACs have been implemented, many, many providers are having to defend themselves from the allegations of, “Fraud.”

I wonder if crying,”Fraud” so many times, like the boy who cried wolf, will create a sense that maybe fraud truly is not being found.  So when the RACs find true fraud, will anyone come running?

Medicaid Story: WRAL 6:00 News Tonight

Today I was interviewed by WRAL.  The interview will be aired during the 6:00 news.  Please watch.

I am so thankful that WRAL saw a story in my client‘s injustice.  My client received a Medicaid termination letter recently, which means that she must discharge all Medicaid recipients and no longer provide Medicaid recipients with the mental health care they need.  She engaged in no fraud.  No, my client provided the mental health services to Medicaid recipients and billed for the services rendered.  The reason she was terminated from Medicaid was because a contracted company for the State decided that her documentation was inadequate (paperwork nit-picking).

Ok, I’m sure that a number of you is sitting there reading this thinking, “Well, her documentation was poor. She should have done a better job.”  No.  Let me explain.

The State has contracted with a couple of companies to audit Medicaid, Recovery Audit Contractors (RACs).  These companies are compensated on a contingent fee, meaning the more errors the companies find, the more money the companies receive.  A RAC audited my client’s documents.  My client provides mental health services (which receive prior authorization).  The RAC is auditing claims from 2009-2010.  So all the claims have been approved back in 2009-2010 by ValueOptions, the State’s contracted company to approve mental health services.  Now, in 2013, the RAC is claiming that the very documentation that was approved in 2009-2010, is now inadequate.

The problem? (And the problem I have seen over and over with many health care providers):

The contracted companies are not being overseen by the State. They have full reign. Unfortunately, many times, the RACs are applying the Medicaid policy requirements from 2013 to Medicaid claims from 2009-2010.  Meaning, the contracted companies are reviewing the current policies and applying them retroactively.

My favorite example of this (not necessarily applicable to my client in this instance) is Implementation Update #68. In Implementation Update #68, the State changed the practice of using an Introductory Person-Centered Plan (Intro PCP).  Before Implementation Update #68, an Intro PCP was written prior to any assessment.  Yet, I have had instances with clients in which the State (via its contracted companies) has stated that a health care provider owed the Medicaid reimbursement back to the State because the Intro PCP was dated prior to the assessment. Yes, NOW, the PCP will be dated after the assessment. But not back in 2009. Therefore, the contracted companies are using the criteria from current policies to audit Medicaid claims from the past.

Why is this important? Today, health care providers who accept Medicaid are getting audits, causing those health care providers to expend time, money and man-power on defending the claims. Who loses? The Medicaid recipients who need the services.  Already, a small percentage of health care providers accept Medicaid.  Medicaid recipients need health care providers willing to see them.

We are appealing my client’s termination of her Medicaid contract.  But the potential consequences (should our appeal not work) are dire. The Medicaid recipients receiving mental health services from my client will need to be discharged.  These people in need of mental health care, will have to find another psychologist, when over 60% of health care providers refuse to accept Medicaid.

Shouldn’t we, as a population, be grateful to health care providers who decide to accept Medicaid recipients? We are not paying high enough reimbursements already, most providers refuse Medicaid recipients. So when a health care provider does accept Medicaid, we should say, “Thank you.” Not scrutinize the documentation (when the services were provided) and say, “Hey, those documents are not compliant with 2013 standards. Yeah, I know the services were provided in 2009, but you should have had a crystal ball and known the policies would become more stringent. Your fault.”

Expansion of NC Medicaid Recoupments

Medicaid recoupments actions have skyrocketed in the past year.  But, in the upcoming year, a new group of health care providers will be targeted for recoupment actions.  According to the February 2013 Medicaid Bulletin, health care providers that  serve the Medicaid population with inpatient and outpatient hospital care, long-term care, laboratory services, x-ray services, and specialized outpatient therapy claims.

DMA has partnered with HMS to become the 2nd RAC vendor for North Carolina.

What is a RAC?

In the most simple terms: A RAC is an entity hired by the State to review Medicaid payments to health care providers and, subsequently, recoup the Medicaid overpayents for the State.

This past year hundreds of health care providers in the mental health fields, personal care services, and outpatient behavioral health services have received Tentative Notices of Overpayment. Some Notices claim repayment amounts in the millions.

Well, now, on to the hospitals…Imagine how large hospital recoupments will be….


Medicaid Recipients Under 21: Not Allowed to Self-Refer Selves to Mental Health Services

In the wake of the killings in Connecticut and with all the recent discussions nationally about mental health, I realized something yesterday that floored me:

In North Carolina, an 18-year-old Medicaid recipient is not allowed to self-refer him or herself to a therapist.

According to DMA Clinical Policy 8C, a Medicaid recipient,  under the age of 21, who wants to seek mental health services by a therapist (Outpatient Behavioral Health services) is required to have an “individual, verbal or written referral, based on the beneficiary’s treatment needs by a Community Care of North Carolina/Carolina Access (CCNC/CA) primary care provider, the LME-MCO or a Medicaid-enrolled psychiatrist.”

Medicaid recipients over the age of 21 can self-refer him or herself to mental health services.

Adam Lanza, the boy who shot so many innocent children and teachers in Connecticut, was 20-years-old at the time of the horrible event.

Yet, if he lived in North Carolina, he could not have self-referred himself to receive therapy.  He would have needed to see a doctor first.

I understand that Medicaid recipients under the age of 21 CAN see a therapist. But, by placing another hoop for them to jump through (seeing another doctor first), just makes it that much harder to receive therapy. If access to mental  health services is that important, why make it more difficult for Medicaid recipients under 21?

Surely, a 20-year-old Medicaid recipient has the capability to determine whether he or she is in need of therapy.


Obama Voices the Need for Access to Mental Health Care: Medicaid Recipients, Too?

Two days ago, Obama voiced that gun control and mental health care reform is on the horizon.  Since the terrible massacre at Sandy Hook Elementary School, people, especially politicians, have been talking about gun control.  The thinking behind this is that if the shooter at Sandy Hook did not have access to guns, the murders would not have happened.  Agreed.

But think of this:  If a child puts his or her finger in a light socket and gets electrocuted, do we cut off the power to the entire house forever? Or do we educate that child so he or she does not do it again?

Personally, I opt for the latter:  Educate.

If the child is incapable of understanding the concept of getting electrocuted by placing his or her finger in a light socket (i.e., the child has mental health issues), then, as a parent, I would seek mental health services for my child.  I still would not opt to cut off the power in the house.

Mental health services are vital.  Mental health services are important for all people. But since this is a Medicaid blog, I will focus on mental health services for Medicaid recipients.  Medicaid recipients need access to quality mental health services. Quite possibly, in the world of Medicaid, mental health services may be the most needed and least provided to recipients (maybe dental and specialities in medicine are also in the top most needed and least provided, but I will cover those topics in another blog).

I’m not talking about mental health services for the autistic children or children suffering from an easily diagnosed and highly recognizable mental health illness. These children obviously need mental health services.  In my opinion, most people would agree as to the need for mental health services to these children.  No, I’m talking about the thirteen year old girl who has so much anger built up inside that she begins to cut herself, torture animals and scream at her teachers. Or the 14-year-old boy, who was sexually abused by his uncle and is now exploring the sexuality of the 6 and 7-year-old boys in the school  bathroom. The 12-year-old boy who has no friends, is isolated at school, and is publicly ridiculed until he begins to think he has no reason to live and begins fantasizing about killings, both of himself and others…the ones who ridicule him.

Would wonderful access to mental health services for Medicaid recipients have stopped Sandy Hook from happening? Probably not. But future tragedies can be stopped by providing quality mental health services to all, especially to Medicaid recipients.  According to Obama’s recent speech, Obama agrees that quality mental health care needs to be accessible to all people.  But does that also mean Medicaid recipients? Medicaid recipients must meet criteria to receive therapy (after a certain number of visits).

Medicaid recipients rely on the Medicaid system for mental health services. I don’t mean to state the obvious, but think about it. People with private health insurance have choices about therapists. I can say, “I’m feel like my depression is overwhelming.” And schedule a psych visit for the next week. Not Medicaid recipients. Medicaid recipients need (for the most part) prior authorization. Which means if a Medicaid recipient feels low…really low…as in, needs a psychiatrist low, they need permission from the State.   A State-contracted agent must review the documents and determine it is medically necessary for that Medicaid recipient to receive therapy.  Although, for Outpatient Behavioral Services,

This is the criteria for a Medicaid recipient to receive Outpatient Behavioral Services:

Entrance Criteria

ALL of the following criteria are necessary for admission of a beneficiary for outpatient treatment services:

a.   A Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,Text Revision (DSM-IV-TR) (or its successors) Axis I or II diagnosis.

b. Presentation with behavioral, psychological, or biological dysfunction and functional impairment, which are consistent and associated with the DSM-IV-TR (or its successors) Axis I or II diagnosis.

c. Does not require a higher level of care.

d. Capable of developing skills to manage symptoms, make behavioral changes,and respond favorably to therapeutic interventions.

e. There is no evidence to support that alternative interventions would be more effective, based on North Carolina community practice standards (e.g., Best Practice Guidelines of the American Academy of Child and Adolescent Psychiatry, American Psychiatric Association, American Board of Addiction Medicine).

Medicaid beneficiaries under 21 and NCHC beneficiaries are allowed 16 unmanaged visits; adults are allowed eight unmanaged visits per calendar year. All visits beyond these limitations require prior approval.

More than eliminating guns (or cutting the power off in the house), Medicaid recipients need somewhere to go to receive quality health care with no judgment and not all this criteria. If a Medicaid recipients wants to attend weekly therapy sessions, shouldn’t the Medicaid recipient be able to go to therapy without needing an Axis I or II diagnosis? Why does a Medicaid recipient need to be diagnosed with an Axis I or II diagnose in order to receive outpatient therapy?

So now Obama has publicly announced that, along with gun control measures, he plans to tackle the issue of mental health care.  I ask, “How?” and “Does this include access to therapy for Medicaid recipients?” The fact is that Medicaid recipients can see a therapist 16 (if a child) and 8 (if an adult) times. But then, the Medicaid recipient must show medical necessity in order to receive therapy. Is this quality mental health care? Is this access to quality mental health care for ALL?


Tip #6: Avoiding Medicaid Recoupments

This tip, Tip #6, is devoted to Outpatient Behavioral Health providers.

Outpatient Behavioral Health providers are licensed psychologists or psychologists who provide mental health counseling to Medicaid recipients.In light of the recent mass murder in Connecticut, I believe that most people would agree that the ability for anyone to receive mental health services is of utmost importance. In my opinion, mental health services are the most needed and most under-used health care service.  In the debate between guns and violent video games, I say that mental health issues and mental health care services trump both.  Create a society in which mental illnesses are (not necessarily accepted) but not stigmatized, people are comfortable asking for help regarding mental illnesses, people can identify others who are in need of counseling, and all people, no matter their insurance coverage,  have access to mental health care services.  Create this society and this society equals violent crimes under control.  A society in which a gun is merely a gun. For hunting, protection of family, or sport…not a weapon of mass destruction.  Mental health awareness is the key.

Ok, enough of my soap box.

In North Carolina, Outpatient Behavioral Health providers are bound by NC DMA Clinical Coverage Policy No. 8C.  Policy No. 8C is much shorter in length than most clinical policies. It’s terseness is a thing of beauty for the Outpatient Behavioral Health providers.

Herein lies tip #6:

Because 8C is so short, so terse, all Outpatient Behavioral Health providers should print off Policy No. 8C and fasten it onto the walls of the office (at least the meaty portions…not the beginning and ending fluff).

Outpatient Behavioral Health providers should have Policy 8C memorized.  Outpatient Behavioral Health providers should dream about Policy 8C.  Outpatient Behavioral Health providers should be able to regurgitate the meat of Policy 8C   …..I mean, come on, people, Policy 8C is 31 pages.  Without the fluff (just the meat) Policy 8C is only, in my opinion, 10 pages of meat…10 pages (pages 7-17)!!!! If the Outpatient Behavioral Health providers memorize a mere 10 pages, the Outpatient Behavioral Health providers will be able to thwart potential reconsideration reviews. Even if the State threatens or begins a reconsideration review, if the Outpatient Behavioral Health providers have memorized these 10 meaty pages, the Outpatient Behavioral Health providers will easily be able to defend the reconsideration review based on documentation and, thus, avoid any alleged overpayments. (After page 17 is important to follow in practice: it consists of billing codes and revisions to past policies, but 17-31 is not the “meat” regulating Outpatient Behavioral Health providers).

For this blog, I am concentrating on Section 7.3.3.  Section 7.3.3 is, by far, the biggest reason Outpatient Behavioral Health providers get dinged in Medicaid audits….BY FAR.  Service notes….really? YES.

Service notes are detail-oriented. Tedious. And one mistake on a service note…I mean a SMALL mistake…will cause the State to attempt to recoup the Medicaid payment bestowed for the entire service rendered. For example, an Outpatient Behavioral Health provider gets prior authorization from the correct state-contracted entity , a valid referral by a Carolina ACCESS primary care physician, a signed consent by the Medicaid recipient, a regulatory-correct Comprehension Clinical Assessment, a valid Treatment Plan and Service Plan… BUT….on the service note for one day…one couseling session….forgets to describe the Medicaid recipient’s reaction to the counseling. Or forgets to put the duration of the session (writes 6pm, but forgets to write that the session ended at 7pm). Or forgets to describe the nonverbal journal-writing session and bills for the play treatment (a higher-reimbursable code). What happens? A Medicaid audit.

According to Policy 8C, there must be a progress note for each treatment encounter that includes the following information (And, people, this is NOT difficult. This is the minimum and easy to meet):

  1. Date of service;
  2. Name of the service provided (e.g., Outpatient Therapy – Individual/Family Tx);
  3. Type of contact (face-to-face, phone call, collateral); non-face-to-face services are not covered and not reimbursable;
  4. Purpose of the contact (tied to the specific goals in the  Tx plan);
  5. Description of the treatment or interventions performed. Treatment and interventions must include active engagement of the individual and relate to the goals and strategies outlined on the individual’s plan;
  6. Effectiveness of the intervention(s) and the beneficiary’s response or progress toward goal(s);
  7. The duration of the service (e.g., length of the assessment or treatment in minutes; Pharmacological Management does not require documentation of the duration of service); and
  8. Signature, with credentials, degree, and licensure of clinician who provided the service. Electronic signatures must adhere to DMA guidelines. A handwritten note requires a handwritten signature; however, the credentials, degree, and licensure may be typed, printed, or stamped.
  9. Service notes must be written in such a way that there is substance, efficacy, and value. Interventions, treatment, and supports must all address the goal(s) listed in the plan. They must be written in a meaningful way so that the notes collectively outline the beneficiary’s response to treatment, interventions, and supports in a sequential, logical, and easy-to-follow manner over the course of service.

Is this difficult? No. Not rocket science.  I suggest creating a template. The template should have a space for every required component of the service note. Print off hundreds…no thousands.  Keep the print-offs in a location that all employees, if present, know of and make them understand that every service note must adhere to the template. Completely. No short-cuts.  No…”I forgot.”  Follow the template.

The result?  The Department of Health and Human Services (DHHS) or any of its entities or contracted companies will be able to audit any service note, written by any employee or you, and say, “This Outpatient Behavioral Health provider has met the minimum requirements of Policy 8C; therefore, there is no reason to try to recoup Medicaid funds from this provider. This provider has followed the rules.”

Wow. Shock and awe. Could that happen? Yes: MEMORIZE THE MEATY 10 PAGES OF POLICY 8C!!!!! And you too could avoid Medicaid recoupments.