Category Archives: Psychologists
“You’re fired!” President Trump has quite a bit of practice saying this line from The Apprentice. Recently, former AG Sally Yates was on the receiving end of the line. “It’s not personal. It’s just business.”
The Yates Memo created quite a ruckus when it was first disseminated. All of a sudden, executives of health care agencies were warned that they could be held individually accountable for actions of the agency.
What is the Yates Memo?
The Yates Memo is a memorandum written by Sally Quillian Yates, former Deputy Attorney General for the U.S. Dept. of Justice, dated September 9, 2015.
It basically outlines how federal investigations for corporate fraud or misconduct should be conducted and what will be expected from the corporation getting investigated. It was not written specifically about health care providers; it is a general memo outlining the investigations of corporate wrongdoing across the board. But it is germane to health care providers.
January 31, 2017, Sally Yates was fired by Trump. So what happens to her memo?
With Yates terminated, will the memo that has shaken corporate America that bears her name go as well? Newly appointed Attorney General Jeff Sessions wrote his own memo on March 8, 2017, entitled “Memorandum for all Federal Prosecutors.” it directs prosecutors to focus not on corporate crime, but on violent crime. However, investigations into potential fraud cases and scrutiny on providers appear to remain a top priority under the new administration, as President Donald Trump’s proposed budget plan for fiscal year 2018 included a $70 million boost in funding for the Health Care Fraud and Abuse Control program.
Despite Sessions vow to focus on violent crimes, he has been clear that health care fraud remains a high priority. At his confirmation, Sessions said: “Sometimes, it seems to me, Sen. Hirono, that the corporate officers who caused the problem should be subjected to more severe punishment than the stockholders of the company who didn’t know anything about it.” – a quote which definitely demonstrates Sessions aligns with the Yates Memo.
By law, companies, like individuals, are not required to cooperate with the Justice Department during an investigation. The Yates Memo incentivizes executives to cooperate. However, the concept was not novel. Section 9-28.700 of the U.S. Attorneys’ Manual, states: “Cooperation is a potential mitigating factor, by which a corporation – just like any other subject of a criminal investigation – can gain credit in a case that otherwise is appropriate for indictment and prosecution.”
Even though Trump’s proposed budget decreases the Department of Justice’s budget, generally, the increase in the budget for the Health Care Fraud and Abuse Control program is indicative of this administration’s focus on fraud, waste, and abuse.
Providers accused of fraud, waste, or abuse suffer extreme consequences. 42 CFR 455.23 requires states to suspend Medicaid reimbursements upon credible allegations of fraud. The suspension, in many instances, lead to the death of the agency – prior to any allegations being substantiated. Just look at what happened in New Mexico. See blog. And the timeline created by The Santa Fe New Mexican.
When providers are accused of Medicare/caid fraud, they need serious legal representation, but with the suspension in place, many cannot afford to defend themselves.
I am “all for” increasing scrutiny on Medicare/caid fraud, waste, and abuse, but, I believe that due process protection should also be equally ramped up. Even criminals get due process.
The upshot regarding the Yates Memo? Firing Yates did not erase the Yates Memo. Expect Sessions and Trump to continue supporting the Yates Memo and holding executives personally accountable for health care fraud – no more hiding behind the Inc. or LLC. Because firing former AG Yates, did nothing to the Yates Memo…at least not yet.
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!
On July 1, 2014, Cardinal Innovations, one of NC’s managed care organizations (MCOs) granted its former CEO, Ms. Pam Shipman, a 53% salary increase, raising her salary to $400,000/year. In addition to the raise, Cardinal issued Ms. Shipman a $65,000 bonus based on 2013-2014 performance.
$400,000 a year, plus bonuses. Apparently, I got into the wrong career; the public sector seems to pay substantially more.
Then in July 2015, according to the article in the Charlotte Observer, Cardinals paid Ms. Shipman an additional $424,975, as severance. Within one year, Ms. Shipman was paid by Cardinal a whopping $889,975. Almost one million dollars!!!! To manage 16 counties’ behavioral health care services for Medicaid recipients.
For comparison purposes, the President of the United States earns $400,000/year (to run the entire country). Does the CEO of Cardinal equate to the President of the United States? Like the President, the CEO of Cardinal, along with all the other MCOs’ CEOs, are compensated with tax dollars.
Remember that the entire purpose of the MCO system is to decrease the risk of Medicaid budget overspending by placing the financial risk of overspending on the MCO instead of the State. In theory, the MCOs would be apt to conservatively spend funds and more carefully monitor the behavioral health care services provided to consumers within its catchment area to ensure medically necessity and not wasteful, unnecessary services.
Also, in theory, if the mission of the MCOs were to provide top-quality, medically necessary, behavioral health care services for all Medicaid recipients in need within its catchment area, as the MCOs often tout, then, theoretically, the MCOs would decrease administrative costs in order to provide higher quality, beefier services, increase reimbursement rates to incentivize health care providers to accept Medicaid, and maybe, even, not build a brand, new, stand-alone facility with top-notch technology and a cafeteria that looks how I would imagine Googles’ to look.
Here is how Cardinal’s building was described in 2010:
This new three-story, 79,000-square-foot facility is divided into two separate structures joined by a connecting bridge. The 69,000-square-foot building houses the regional headquarters and includes Class A office space with conference rooms on each floor and a fully equipped corporate board room. This building also houses a consumer gallery and a staff cafe offering an outdoor dining area on a cantilevered balcony overlooking a landscaped ravine. The 10,000-square-foot connecting building houses a corporate training center. Computer access flooring is installed throughout the facility and is supported by a large server room to maintain redundancy of information flow.
The MCOs are not private companies. They do not sell products or services. Our tax dollars comprise the MCOs’ budget. Here is a breakdown of Cardinal’s budgetary sources from last year.
The so-called “revenues” are not revenues; they are tax dollars…our tax dollars.
78.1% of Cardinal’s budget, in 2014, came from our Medicaid budget. The remaining 21.7% came from state, federal, and county tax dollars, leaving .2% in the “other” category.
Because Cardinal’s budget is created with tax dollars, Cardinal is a public company working for all of us, tax paying, NC, residents.
When we hear that Tim Cook, Apple’s CEO, received $9.22 million in compensation last year, we only contributed to his salary if we bought Apple products. If I never bought an Apple product, then his extraordinarily high salary is irrelevant to me. If I did buy an Apple product, then my purchase was a voluntary choice to increase Apple’s profits, or revenues.
When we hear that Cardinal Innovations paid $424,975 to ousted CEO, Pam Shipman, over and above her normal salary of $400,000 a year, we all contributed to Shipman’s compensation involuntarily. Similarly, the new CEO, Richard Toppings, received a raise when he became CEO to increase his salary to $400,000 a year. Again, we contributed to his salary.
A private company must answer to its Board of Directors. But an MCO, such as Cardinal, must answer to tax payers.
I work very hard, and I expect that my dollars be used intelligently and for the betterment of society as a whole. Isn’t that the purpose of taxes? I do not pay taxes in order for Cardinal to pay its CEO $400,000.
For better or for worse, a large percentage of our tax dollars, here in NC, go to the Medicaid budget. I would venture that most people would agree that, as a society, we have a moral responsibility to ensure that our most vulnerable population…our poorest citizens…have adequate health care. No one should be denied medical coverage and our physicians cannot be expected to dole out charity beyond their means.
We know that Medicaid recipients have a difficult time finding physicians who will accept Medicaid. We know that a Medicaid card is inferior to a private payor card and limits provider choice and allowable services. We know that certain services for which our private insurances pay, simply, are not covered by Medicaid. Why should a Medicaid-insured person receive sub-par medical services or have more difficulty finding willing providers, while privately insured persons receive high quality medical care with little effort? See blog or blog.
Part of the trouble with Medicaid is the low reimbursements given to health care providers. Health-care consulting firm Merritt Hawkins conducted a study of Medicaid acceptance rates which found that just 45.7 percent of physicians are now accepting Medicaid patients in the U.S.’s largest 15 cities and the numbers worsen when you look at sub-specialties.
The reimbursement rates are so low for health care providers; the Medicaid services are inadequate, at best; and people in need of care have difficulty finding Medicaid physicians. Yet the CEO of Cardinal Innovations is compensated $400,000 per year.
Cardinal has 635 employees. Its five, top-paid executives are compensated $284,000-$400,000 with bonuses ranging $56,500-$122,000.
Richard Topping, Cardinal’s new CEO, told the Charlotte Observer that “it doesn’t cut into Medicaid services.”
He was also quoted as saying, “It’s a lot of money. It is. You’ve just got to look at the size and the scope and the scale.”
In contrast, Governor McCrory is compensated approximately $128,000. Is McCrory’s “size, scope, and scale” smaller than the CEO’s of Cardinal? Is the CEO of Cardinal “size and scope and scale,” more akin to the President of the US?
“We are a public entity that acts like a private company for a public purpose,” Toppings says. Each MCO’s Board of Directors approve salaries and bonuses.
Cardinal is not the only MCO in NC compensating its CEO very well. However, according to the Charlotte Observer, Cardinal’s CEO’s compensation takes the cake.
Smokey Mountain Center (SMC) pays its Chief Medical Officer Craig Martin $284,000 with a $6,789 longevity bonus.
Four years ago, before the initial 11 MCOs, the administrative cost of the MCOs was nonexistent (except for the pilot program, Piedmont Behavioral Health, which is Cardinal now). Implementing the MCO system increased administrative costs, without question. But by how much? How much additional administrative costs are acceptable?
Is it acceptable to pay $400,000+ for a CEO of a public entity with our tax dollars?
Smoke and Mirrors: ECBH Increasing Medicaid Rates (But Decreasing the Amount of Services Authorized?)
I am always amazed at magicians. David Copperfield, David Blaine…
I once saw David Copperfield live. I was convinced prior to the show that I would be able to determine how he performed the illusions. I just KNEW that I would see the strings or the trapdoor. But I did not. I was thoroughly amazed. Despite the fact that I still know that magic is not real, I was still awe-struck and entertained. Realistically, magic is just smoke and mirrors. But, dag on, those smoke and mirrors do a fantastic job. At times, while watching a magic show, I find myself actually believing in magic. That is the power of smoke and mirrors.
Smoke and mirrors do not only appear in magic. Many politicians are expert wielders of smoke and mirrors. So to are many salesmen. And, apparently, East Carolina Behavioral Health (ECBH).
An article was published on NC Health News’ website yesterday. “Medicaid LME Updates: Cumberland/Alliance to Merge, Good News from ECBH.” Article is good. Information is good. But the ECBH news, I find “smoky.”
Click here for the article by Taylor Sisk
According to the article, “ECBH will increase the rates for psychological testing by 10 percent, personal care services by 16 percent, peer support by 7 percent and facility-based crisis and detoxification services to cover the full cost of the service.”
On the surface, the increase in rates that ECBH is implementing sounds great, right? In my head, I thought, “Wow! ECBH is doing some great marketing. Providers will want to work with ECBH…”
The problem is that the “surface level” or rate increase “on its face” is never the whole story. (Which is why ECBH’s rate increase is such an amazing use of smoke and mirrors. Most people will never see past the smoke).
The MCOs are prepaid. If the MCOs’ do NOT contract with providers and NOT authorize services, profits rise.
But would an MCO REALLY deny medically necessary services, theoretically, to INCREASE profit?? You can decide.
However, one of my clients hired me because ECBH denied 100% of continuing authorizations and new referrals for ACTT services in Pitt County.
ONE HUNDRED PERCENT!
What are ACTT services?
DMA Clinical Policy 8A defines ACTT services:
“The Assertive Community Treatment Team [ACTT] is a service provided by an interdisciplinary team that ensures service availability 24 hours a day, 7 days per week and is prepared to carry out a full range of treatment functions wherever and whenever needed. A service beneficiary is referred to the Assertive Community Treatment Team service when it has been determined that his or her needs are so pervasive or unpredictable that they cannot be met effectively by any other combination of available community services. Typically this service should be targeted to the 10% of MHDDSA service beneficiaries who have serious and persistent mental illness or co-occurring disorders, dual and triply diagnosed and the most complex and expensive treatment needs.”
ACTT services are reserved for the extremely mentally ill. These are the people who need 24-hour services; recipients receiving ACTT services are people who must receive the ACTT services to function. Yet, ECBH denied 100% of my client’s new referrals and continuing authorizations. One such denial was a Medicaid recipient who had been arrested 6 times since April 2012. After the ACTT denial, the Medicaid recipient was again incarcerated, which is where the recipient is now. Another denial resulted in the Medicaid recipient being hospitalized for suicidal ideation.
For recipients already receiving ACTT services, ECBH has forced my client to “step-down” the recipients to outpatient behavioral therapy (“OBT”). Of the Medicaid recipients that ECBH has forced Petitioner to “step-down,” three recipients were immediately referred back to ACTT when the OBT providers stated that the recipients suffered too high acuity of mental health illness to manage in OBT setting. Two recipients were incarnated after discharge; the jail employees are complaining of psychiatric problems that are difficult to manage.
Back in May 2013, the local news channel in Greenville, North Carolina, aired “9 On Your Side Mental Health Town Hall exposes problems, brings you answers.” The news channel coverage demonstrates the possibility of the widespread breath of ECBH denials, in general. Maybe ECBH’s denials of medically necessary services is not limited to my client’s personal situation.
Regardless of the breadth of ECBH’s denials of medically necessary services, back in May 2013, ECBH was getting some bad marketing from the local news. So what does ECBH do? Raise reimbursement rates.
If, in fact, ECBH is denying many medically necessary Medicaid services in order to raise profit, then isn’t ECBH’s rate increase just smoke and mirrors?
Number of Mental Health Patients Rise in ERs as Willing/Able Medicaid Behavioral Health Providers Dwindle
This is EXACTLY the issue that I have been blogging about for months. The State of North Carolina, for whatever reason, has determined (whether intentional or not) to decrease the number of behavioral health care providers who accept Medicaid. With the aggressive tools in the Division of Medical Assistance’s (DMA) work shed, such as outrageous Tentative Notices of Overpayments, capricious prepayment review audits, and arbitrary terminations of Medicaid contracts without affording due process, DMA has, in the last year or so, successfully bankrupt hundreds of Medicaid behavioral health providers. Or the providers simply washes their hands of Medicaid all together.
With the dramatic decrease in Medicaid mental health providers, where are all the Medicaid recipients going? One answer? The ERs.
People in the industry are also noticing.
My best friend is an ER nurse. She told me recently that she noticed more and more patients coming in to the ER with mental illness the primary diagnosis. I asked her whether she knew whether these patients with primary mental health diagnoses were Medicaid patients. She answered (which I love), “I don’t know. I never look to see if a patient is a Medicaid recipient. I treat them all the same.” She is a good nurse.
Anyway, I asked her to start paying attention (without ever providing me with specific information). She returned a week or so later saying that, yes, the patients with mental illness as the primary diagnosis generally seem to be Medicaid recipients. (In fact the night before a man came in the ER sticking his tongue in and out rapidly and screaming, “Get me my lily pad!” This is not a man who should be in the ER. This man should be receiving mental health services).
Others in the industry have noticed this growing issue of Medicaid recipients with mental illness as the primary diagnosis going to the ER as well. Dr. Judy Tintinalli, an ER physician noticed and researched the issue. Here is her article:
NC Emergency Patients Twice as Likely to Have Mental Health Problems
June 17, 2013 by Rose Hoban
Research published by the Centers for Disease Control and Prevention compared rates of people reporting to North Carolina’s emergency departments complaining of mental health issues to EDs in the rest of the country.
By Rose Hoban
Many people think of emergency departments as mostly treating patients with traumas or heart attacks or an out-of-control infection. But in 2010, Judy Tintinalli, an emergency department physician at UNC Hospitals, was getting the sense that she was seeing more and more patients coming into her emergency department with mental health problems. She started asking around and found she wasn’t the only one with this impression. “We’d all noticed that the number of mental health diagnoses in visits are just going up in EDs,” Tintinalli said. “And this has been going on for a while.” Source: Emergency Department Visits by Patients with Mental Health Disorders — North Carolina, 2008–2010, MMWR 62(23);469-472 So she and her colleagues from several states started work on a study to look at rates of people coming in for care with mental health issues as one of their main complaints. Tintinalli’s intuition was on target. In a paper published last week, she writes that while rates of mental health issues in emergency departments are up all over the country, they’re especially high in North Carolina. Patients who came to emergency departments in the state between the beginning of 2008 and the end of 2010 were twice as likely to have a mental health complaint than in the rest of the country.
According to the Centers for Disease Control and Prevention, in 2009, about 5 percent of people coming into emergency rooms had a mental health disorder. But at that time, North Carolina’s rate was almost double, according to Tintinalli’s study. She used data that comes from almost every emergency department in the state, a system called the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT). The system, begun as a way to catch bioterrorism or disease outbreaks before they get out of control, collects data about the diagnoses of every visitor to North Carolina’s emergency departments. NC DETECT captures more than four million emergency department visits per year. No personal data is collected, just geographic data and information about what happened during the visit. The system collects up to 10 possible diagnoses for each patient encounter. “And at the end of the patient encounter, you list the diagnoses the patient had,” Tintinalli said. “You prioritize based on how critical they are. “So, say you have someone come in with cancer, and they have pneumonia, and they’re also depressed; depression is the third diagnosis. If you come in saying you want to kill yourself, then the depression will be the first diagnosis.” By the end of 2010, 9.3 percent of all ED visits had a mental health problem as one of the top complaints.
NC DETECT draws data from many sources and provides surveillance data to NC public health as well as to CDC. Diagram courtesy North Carolina Preparedness and Emergency Response Research Center
And Tintinalli found that not only were people coming in for mental health disorders, but those people with a main complaint of mental health problems were more than twice as likely to be admitted to the hospital. No surprise. Clinical social worker Bebe Smith, who teaches at the UNC School of Social Work, said she wasn’t surprised to hear that North Carolina has had higher rates of emergency department usage among people with mental health issues. “North Carolina’s mental health system has been in constant flux for over a decade,” Smith said. “Sometimes people end up going to the ER when they’re truly suicidal and despairing and overwhelmed by stress. You know, if there are psychosocial stressors like losing a job, you don’t want to go on, you start drinking, get suicidal,” Smith said. She said it’s called being “in crisis,” and it looks slightly different for each patient. Tintinalli’s data showed that close to two-thirds of people coming in with mental health problems were complaining of stress, anxiety or depression.
“We let people go into crisis,” said Vicki Smith, head of Disability Rights North Carolina, who pointed to the lack of community-based services for people with mental health problems. “We are not providing people with mental health needs the services they need to keep them out of crisis,” she said. “We allow them to go into crisis and they end up in the ED, sometimes via police cars.”
“If numbers are going up, we need to look and ask if we have adequate resources to really deal with these problems statewide,” Tintinalli said. Vicki Smith said that’s exactly the problem. “We can keep people out of EDs, and there are a lot of evidence-based practices to do that,” she said. “But we haven’t provided the resources.”
Severe and persistent
A lot of providers of care for people with severe and persistent mental illness, like schizophrenia or bipolar disorder, have gone out of business, Bebe Smith said. And when that happens, patients lose their continuity of care. “That’s something important for them,” she said, “and it’s something we’ve lost.” She also said that the state has shifted away from continuous provision of care for these people – who often are disabled enough to have Medicaid –into episodic care, as a way to save dollars. “So people might have been in treatment for a while, they do better and then we discharge them,” Bebe Smith said. She said many outpatient clinics have pushed providers into seeing more patients for shorter visits as a way of getting productivity – and revenues – up. Then if patients start to do poorly, they get lost. “So if someone misses the appointment, they don’t have time to check in on that person. But the people who are doing more poorly are the ones who need outreach,” Smith said. “The way they’ve pushed productivity levels on therapeutic workers – that’s another place where you lose the continuity that’s key in keeping people from crisis.” So, she said, many end up in the facility of last resort – emergency departments.