Category Archives: Plan of Care

CCME’s Medicaid Audit Bloopers: Ring Around the Rosie, We All Fall Down

May 8

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“Ring Around the Rosie.” What a fantastic children’s rhyme; it brings back nostalgic memories of my daughter being young. We would sing “Ring Around the Rosie,” while holding hands and running in a circle, and then fall as hard as possible (without hurting ourselves) onto the ground. We would just flop on the ground and my daughter loved it.

Although many people believe that the rhyme describes the time during the Great Plague in England in 1665, which is pretty morbid, it is still a fun children’s game.

But other than “Ring Around the Rosie,” it is no fun to run in circles until you get dizzy and fall to the ground. People usually just don’t spin around and around for fun.

Sometimes going through a Medicaid or Medicare audit can feel like you are running around and around in circles and getting ready to fall. So too, can you feel this way if you are undergoing a prepayment review with the Carolinas Center for Medical Excellence (CCME).

First, what is prepayment review?

N.C. Gen. Stat. 108C-7 allows for prepayment review. See also my blog, “NC Medicaid: CCME’s Comedy of Errors of Prepayment Review.” Or “CCME’s Prepayment Reviews Violate NCGS 108C-7!! Seriously!!“

Prepayment review means that a contracted entity, in this case CCME, reviews your claims BEFORE you get paid for services rendered. While on prepayment review, you do not receive Medicaid reimbursements. This can continue for 12 months or unless you reach 70% accuracy for three consecutive months.

70% doesn’t sound too hard, right? But, what if the auditing entity runs you in circles, gets you dizzy and makes you fall to the floor?

Here’s the story:

A client of mine owns a home health care company. She and her staff provide personal care services (PCS) to those who are eligible. For those who do not know what PCS is, it is basic caregiving services to help people with activities of daily living (ADLs), such as toileting, dressing, and eating.

My client, we will call her Provider Nancy, was undergoing a prepayment review that had been conducted by The Carolinas Center for Medical Excellence (CCME).

We won’t even talk about the fact that by the time Nancy came to me she had been on prepayment review for 17 months, but that the statute, NCGS 108C-7, only allows a provider to be on prepayment review for 12 months.

When she was undergoing prepayment review, CCME gave her low accuracy rates for a number of reasons, some of which were so absurd, you will laugh out loud.

For example, CCME denied claims because the service notes did not denote that the in-home aid put shoes on two of her clients. There were multiple dates of service (DOS) so these two clients contributed heavily to her low accuracy rating. I asked Nancy why the service note did not denote that her staff put shoes on her clients. She told me that these clients are double amputees. They do not have feet. So Nancy was dinged in her audit for not putting on shoes on someone without feet.

Nancy’s story also highlights the confusion at CCME about its own prior authorization records for PCS. CCME repeatedly demanded a copy of the authorization for Nancy to provide PCS. If a provider like Nancy did not have a prior authorization, she would never have received payment in the first place.  Nonetheless, CCME told Nancy to that she had not documented the prior authorizations. Oddly enough, in order to produce the authorizations she had obtained, Nancy had to contact CCME, because at the time of her prepayment review audit, CCME was the entity that reviewed independent assessments to determine prior authorization.  CCME was saying she had no prior authorization, but it was CCME who gave her the prior authorization!!  How can a system operate like this, when an important reviewing entity does not know what is in its own records?

It got worse: Nancy would then ask CCME for CCME’s prior authorization letter,  but CCME could not or would not give her a copy.  Then CCME reps attended the hearing and stated that Nancy was dinged for not having a prior authorization. Can a system get any more backward??

Ring around the rosie…

Sometimes Nancy’s service notes showed that her in-home aids did extra chores for her clients. Maybe an in-home aide would help a client ambulate because the client had sore muscles that particular day, but, according to the plan of care (POC), the client did not need hands-on assistance to ambulate. CCME would ding Nancy for the service note not being in compliance with the POC. Nancy was getting dinged in the prepayment review for doing MORE GOOD for her clients than what was required. It was not as if Nancy’s in-home aides were foregoing aid to the ADLs on the POC. Oh, no! The in-home aid was going over and above the call of duty for a client. And Nancy would get dinged.

We all fall down!

Needless to say, Nancy did not meet the 70% for three consecutive months in order to be removed from prepayment review. But, remember, Nancy was not paid for 17 months; she came to me 17 months into the prepayment review. She was hurting financially.

Now, because of CCME’s confusing and inaccurate review, Nancy had little money and now had to hire a lawyer. Sure, we got her off prepayment review and got her paid, but she had to shell out thousands of dollars for attorneys’ fees.

If you have to undergo “Ring Around the Rosie” during a prepayment review, I think that the auditing entity, in this case CCME, should have to pay for attorneys’ fees. Give some sort of disincentive for the auditing companies to be sloppy. A penalty.

Now Liberty Mutual, not CCME, authorizes PCS.. But CCME continues to conduct prepayment reviews.

Ring around the rosie
Pocket full of posies
Ashes, ashes
We all fall down!

Posted in Administrative Law Judge, Administrative Remedies, Carolinas Center for Medical Excellence, CCME, Division of Medical Assistance, Health Care Providers and Services, Home Health Aide Services, Home Health Services, In Home Care Services, Lawsuit, Legal Analysis, Legal Remedies for Medicaid Providers, Medicaid, Medicaid Appeals, Medicaid Audits, Medicaid Billing, Medicaid Providers, Medicaid Reimbursements, Medicaid Services, Medicare and Medicaid Provider Audits, NC, NC DHHS, NCGS 108C-7, North Carolina, Office of Administrative Hearings, Personal Care Services, Petitions for Contested Cases, Plan of Care, Prepayment Review, Prior Authorization, Regulatory Audits, Service Notes

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Attention: All Medicaid Providers Whose Services Require Prior Authorization: A Way to Increase Revenue and Help Medicaid Recipients…Or…Killing Two Birds with One Stone

Oct 11

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Attention: All Medicaid Providers Whose Services Require Prior Authorization

A Way to Increase Revenue and Help Medicaid Recipients

Have you heard the cliché: “Killing two birds with one stone….?”

The phrase is thought to have originated in the early 1600s when slingshots were primarily used for bird hunting.  (BTW: My husband, who is an expert bird hunter (with guns), I am sure, would be able to hit two birds with one stone…he is that good.  In fact, he may have already shot two birds with one bullet).  Anyway, Thomas Hobbs, an English political philosopher, is generally given credit for coining the phrase in 1656, although Ovid has a similar expression in Latin over 2000 years prior.  Killing two birds with one stone generally means achieving two objectives with one action. (Which, obviously, is a good thing).

For our purposes here, killing two birds with one stone means that by undergoing one action (appealing all Medicaid recipients’ denials, terminations, and reductions for services requiring prior authorization) two positive results are achieved:

1. The Medicaid recipients have their denials, terminations, and reductions appealed (or…people who need services may actually get those necessary services); and

2. Your provider company makes more money.

Not all Medicaid services require prior authorization.  But many do.  Many prescription drugs require prior approval.  Certain services during a pregnancy for a Medicaid pregnant woman require prior authorization. In behavioral health care, almost all services require prior authorizations (although there are some unmanaged visits in outpatient behavioral health (OBT) that do not require prior authorization).  Even though other Medicaid services require prior authorization, this blog and NCGS 108D only applies to behavioral health care (because NCGS 108D applies to MCOs and the MCOs only manage behavioral health care).  You should appeal all other denied, terminated, or reduced Medicaid services that require prior authorization, but the appeal process in this blog pertains to behavioral health care.

Why care about Medicaid recipient appeals?

It is indisputable that people start companies to make money (except 501(c) companies).  You’ve heard all the cliches…”Money makes the world go around…” “The lack of money is the root of all evil…” “Money: power at its most liquid…”

We’ve also heard all the cliches…”Money can’t buy happiness…” “I have no money, no resources, no hope. I am the happiest man alive….” “Money has never made man happy, nor will it, there is nothing in its nature to produce happiness. The more of it one has the more one wants.”

Regardless whether you believe that money is a necessary evil or the key to happiness, it is without question that people need money to get by in life.  Therefore, when people create companies, it is, normally, with the intent to make money.

Medicaid providers are no exception.

True, Medicaid reimbursements are crappy.  But, despite the crappy/low Medicaid reimbursements, Medicaid providers still hope to make some profit…and do good. (2 birds…1 stone).

We all want to make money and help Medicaid recipients, right? (I know I do).

So with my “handy dandy” tips in this blog, you, too, can kill two birds with stone. You can do both: make more money and help Medicaid recipients.

Wait, I thought providers could not appeal on behalf of our clients? I have heard this incorrect statement over and over from multiple clients.  It simply is not true.

NCGS 108D(4)(b) states that “[e]nrollees, or network providers authorized in writing to act on behalf of enrollees, may file requests for grievances and LME/MCO level appeals orally or in writing. However, unless the enrollee or network provider requests an expedited appeal, the oral filing must be followed by a written, signed grievance or appeal.” (emphasis added).

You just need the Medicaid recipient’s consent in writing.

Increased Profit AND Providing Medicaid Services to Recipients: Two Birds…One Stone!

First, how would appealing all terminations, denials and reductions for Medicaid services increase profit for you, as a provider?

For terminations and reductions (not initial authorizations), if you appeal, the Medicaid recipients are required to receive maintenance of service (MOS).  This means that, at the very least (even if you lose), if you appeal, you are able to provide services and be reimbursed for services during the appeal process. 

For example, you have a developmentally disabled (DD) Medicaid client, who has received 8 hours/day personal care services (PCS) for the last 4 years.  You submit your yearly plan of care (POC) requesting 8 hours PCS/day per norm.  The managed care organization (MCO) reduces your client’s PCS to 6 hours/day.  If you timely appeal the reduction or termination, the MCO will be required to reimburse for 8 hours PCS/day throughout the appeal process.

NCGS 108D-6(c) states: “Continuation of Benefits. – An LME/MCO shall continue the enrollee’s benefits during the pendency of a LME/MCO level appeal to the same extent required under 42 C.F.R. § 438.420.”

42 C.F.R. 438.420 states that:

“Continuation of benefits. The MCO or PIHP must continue the enrollee’s benefits if—

(1) The enrollee or the provider files the appeal timely;
(2) The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;
(3) The services were ordered by an authorized provider;
(4) The original period covered by the original authorization has not expired; and
(5) The enrollee requests extension of benefits.

Pay particular attention to subsection (5)…the enrollee must request MOS.  Don’t forget to add that little phrase into the form that you have the enrollee sign to consent to appeal.

MOS allows you to be paid during the appeal AND the Medicaid recipient to receive the medically necessary services during the pendency of the appeal.

Two birds…one stone.

For terminations and reductions, there is no need to ask for an expedited hearing (will discuss momentarily), because with MOS, there is no hurry (the recipient is receiving the needed services and you are getting paid).

So, let’s turn to an initial denial for a Medicaid service that requires prior authorization and the appeal process:

If the MCO denies an initial authorization, the Medicaid recipient is not entitled to MOS.  However, appealing these initial denials are just as important to (a) the recipients; and (b) your profit as appealing the terminations and denials.

But an appeal can takes months and the recipient (assuming medical necessity truly exists) needs the behavioral health care services in order to not decompensate. So how can the appeal help?

Answer: Request an expedited appeal.

NCGS 108D-7 states:

“When the time limits for completing a standard appeal could seriously jeopardize the enrollee’s life or health or ability to attain, maintain, or regain maximum function, an enrollee, or a network provider authorized in writing to act on behalf of an enrollee, has the right to file a request for an expedited appeal of a managed care action no later than 30 days after the mailing date of the notice of managed care action. For expedited appeal requests made by enrollees, the LME/MCO shall determine if the enrollee qualifies for an expedited appeal. For expedited appeal requests made by network providers on behalf of enrollees, the LME/MCO shall presume an expedited appeal is necessary.”

Important: You still have 30 days to appeal.

Even more important: The MCO is required, by statute, to PRESUME an expedited appeal is necessary.

True the General Assembly really gave mentally ill, developmentally disabled, and substance abuse population the shaft when they passed, and McCrory signed, Senate Bill 553, now Session Law 2013-397, by placing the legal burden of proof on the Medicaid recipient in all circumstances (really??), but the small ray of hope is that, at least as it pertains to expedited appeals, the MCO must presume that an expedited appeal is necessary for the well-being of the recipient.

Going back to expedited appeals, the MCO must make “reasonable efforts” (yes, there is too much wiggle room there) to notify the Medicaid recipient/provider of a denial of an expedited appeal within 2 days.  I also believe that is in the best interest of an MCO to authorize expedited appeals, because….could you imagine the implications and legal liability on the MCO if the MCO denies an appeal to be expedited and something horrible happens to the Medicaid recipient as a direct result of the MCO’s refusal to expedite the appeal????  Or, even worse, the recipient harms others as a  result of the appeal not being expedited??? WHOOO HOOOO….talk about bad PR!!!

So, two days to determine whether the MCO will accept the request for an expedited appeal.  How long for a decision?

According to NCGS 108D-7(d), “[i]f the LME/MCO grants a request for an expedited LME/MCO level appeal, the LME/MCO shall resolve the appeal as expeditiously as the enrollee’s health condition requires, and no later than three working days after receiving the request for an expedited appeal. The LME/MCO shall provide the enrollee and all other affected parties with a written notice of resolution by United States mail within this three-day period.”  (emphasis added).

So, basically, if the MCO takes 2 days to decide to accept the expedited appeal, then there is only 1 additional day to determine the results of the appeal.  That is fast…I don’t care who you are!!

If the MCO denies the expedited appeal, then the MCO has 45 days to provide a decision.

Very Important:  Any adverse decision from an MCO is appealable to the Office of Administrative Hearings (OAH).

Ok, recap:  You, as a provider, want to appeal all Medicaid recipient denials, terminations, and reductions for the following two reasons:

1. Increase profitability for your company; and

2. Help the Medicaid recipients by appealing denials, terminations or reductions, and, hopefully, obtaining the medically necessary services for your clients.

Win…win.

2 birds…1 stone.

Posted in Administrative Law Judge, Administrative Remedies, Appeal Deadlines, Behavioral health, Burden of Proof, Denials of Claims, Denials of Medicaid Services, Division of Medical Assistance, Expedited Appeal, Health Care Providers and Services, Lawsuit, Legal Analysis, Legal Remedies for Medicaid Providers, Legislation, Maintenance of Service, MCO, Medicaid, Medicaid Appeals, Medicaid Recipient Appeals, Medicaid Recipients, Medicaid Reimbursements, Medicaid Services, Medical Necessity, Mental Health, Mental Health Problems, Mental Illness, NC, NC DHHS, NCGS 108D, North Carolina, OAH, Office of Administrative Hearings, Plan of Care, Prior Authorization, Reconsideration Reviews

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On Medicaid? Need Home Health Aide Services? You Are Now Limited in Number of Visits.

Jul 9

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New revisions to Medicaid policy limit the number of home health aide services for Medicaid recipients, regardless of medical need.

North Carolina Department of Health and Human Services (DHHS), Division of Medical Assistance (DMA) revised the Clinical Policy 3A. The revised policy took effect July 1, 2013.

Prior to this revised policy, home health aide services were limited to the amount, frequency, and duration of services as  ordered by the physician and documented in the Plan of Care (POC). As in, if you needed services four times a week, if your physician ordered the services and the need for such services were documented on the POC, you could receive home health aide services four times a week.

What are home health aide services?

“Home Health (not aide) Services, generally, include medically necessary skilled nursing services, specialized therapies (physical therapy, speech-language pathology, and occupational therapy), home health aide services, and medical supplies provided to beneficiaries who live in primary private residences. Skilled nursing, specialized therapies, and medical supplies can also be provided if the beneficiary resides in an adult care home (such as a rest home or family care home).”

Home health aide services are a subpart of Home Health Services.

“Home health aide services are hands-on paraprofessional services provided by a Nurse Aide I or II (NA I or NA II) under the supervision of the RN. The services are provided in accordance with the established POC to support or assist the skilled service (skilled nursing and specialized therapies).

Home health aide services help maintain a beneficiary’s health and facilitate treatment of the beneficiary’s illness or injury. Typical tasks include:

a. Assisting with activities such as bathing, caring for hair and teeth, eating, exercising, transferring, and eliminating.

b. Assisting a beneficiary in taking self-administered medications that do not require the skills of a licensed nurse to be provided safely and effectively.

c. Assisting with home maintenance that is incidental to a beneficiary’s medical care needs, such as doing light cleaning, preparing meals, taking out trash, and shopping for groceries.

d. Performing simple delegated tasks such as taking a beneficiary’s temperature, pulse, respiration, and blood pressure; weighing the beneficiary; changing dressings that do not require the skills of a licensed nurse; and reporting changes in the beneficiary’s condition and needs to an appropriate health care professional.”

See DMA Clinical Policy 3A, p. 1-3 (emphasis added).

The revised Policy 3A has 5 additional pages (it went from 29 pages to 34 pages, in total), but many more restrictions, many of which are without regard to medical necessity.

Such as, “Home health aide services must be limited to 100 total visits per year per beneficiary.”  Click here for the full text of the revised Policy 3A. Of course, always remember the exception for children: EPSDT.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a federal Medicaid requirement that requires the state Medicaid agency to cover services, products, or procedures for Medicaid beneficiary under 21 years of age if the service is medically necessary health care  to correct or ameliorate a defect, physical or mental illness, or a condition [health problem] identified through a screening examination (includes any evaluation by a physician or other licensed clinician).

For more information on EPSDT, see my blog: “EPSDT’s Impact on Medicaid Audits.”

 Now, going back to our Medicaid recipient in medical need of 4 home health aide services/week (208 visits/year), he or she is now limited to 100/year (almost 2 visits/week) (This math is using 52 week/year, not 52.1775).

There are other services possible, depending on the medical necessity. But as for home health aide services, you only get 100.

Remember, this limit not only affects Medicaid recipients (obviously the limit impacts the recipients most greatly), but, also, providers will have less work for their home health aides. As one of my readers pointed out to me, the aides are only making around $8/hour.

DMA Clinical Policy 3A, revised July 1, 2013, has other restrictions. See below for some other restrictions.

Skilled Nursing Visits

Pre-filling insulin syringes/Medi-Planner visits (RC 581) must be limited to a maximum of one visit every two (2) weeks with one (1) additional PRN visit allowed each month. There is a limit of 75 skilled nursing visits (inclusive of, and in any combination with, RC 550, RC 551, RC 559, RC 580, RC 581, and RC 589) per beneficiary per state fiscal year.

Miscellaneous Code T1999        

Use of the T1999 code for billing miscellaneous supplies is limited as follows:

  • A maximum of $250 per beneficiary per state fiscal year may be billed without prior approval required.
  • Any amount over $250 per beneficiary per state fiscal year, whether for a single item or a cumulative total, requires prior approval.
  • A maximum of $1,500 per beneficiary per state fiscal year may be billed.

Are these new restrictions only because of a tight Medicaid budget? My question is when does medical necessity for Medicaid recipients become a factor in policy limits?

Posted in Budget, Division of Medical Assistance, DMA Clinical Policies, DMA Clinical Policy 3A, EPSDT, Health Care Providers and Services, Home Health Aide Services, Home Health Services, Medicaid, Medicaid Costs, Medicaid Limits, Medicaid Recipients, Medicaid Recipients Under 21, NC DHHS, North Carolina, Plan of Care, Skilled Nursing Visits

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