Category Archives: NC DMA Clinical Coverage Policy 8C

Medicaid Providers: Know What the “Way Back Machine” Is? Perhaps, You Should!

This blog pertains to all Medicaid providers regardless the state and regardless the Medicaid service provided.

Heard of the “Way Back Machine?”  Perhaps, you should have!!!


You are a Medicaid provider, and you get a Tentative Notice of Overpayment (TNO) based on a Medicaid post-payment review by Public Consulting Group (PCG) or HMS in the extrapolated amount of $800,000 based on a sample size of 100 dates of service (DOS) and multiplied out to some extrapolation universe. You look at the extrapolation data and determine tha you were not even paid $800,000 during the time frame PCG determined was the universe. Or you say…What???…My documents complied with policy!

What do you do?

Sound like a horrible SAT question? Or sound like reality?

Hopefully you answered the former, but if you answered the latter, read on…

You’ve read my blogs before and understand the importance of appealing PCG or HMS’ extrapolated audit.  But you do not have the financial means to hire an attorney.  Or you honestly believe that if the Department of Health and Human Services (DHHS) reviewed your documents that its employees would also agree that PCG or HMS was wrong.  Or you, personally, want to self-audit to determine the veracity of the audit.  Or for whatever reason, you want to know whether PCG or HMS was correct for your own well-being. 

How do you self-audit….the audit?

This may be one of the best “tips” I have given… (sorry for tooting my own horn, but, seriously, this blog can be helpful! I had a client that pointed out he/she had no idea about this “tip.”)

PCG and HMS conduct post-payment reviews.  This means that PCG and HMS are looking at 1-2-3-year-old medical records.

Think about how quickly Medicaid changes.  Now think about the number of times in which the DMA Clinical Policy applicable to your practice has been revised in the last few years.

When I say DMA Clinical Policy, I mean, if you provide Outpatient Behavioral Therapy, Policy 8C is applicable.  If you provide dental services to Medicaid recipients, then Policy 4A is applicable.  If you provide durable medical equipment (DME) to Medicaid providers, then Policy 5A is applicable.  For a full list of the NC Medicaid policies, please click here.

The DMA Clinical Policies change significantly throughout the years.  For example, DMA Clinical Policy 8A, revised January 1, 2009, allowed Community Support for adults and children.  Yet Policy 8A, revised August 1, 2013, does not even allow Community Support (obviously Community Support was disallowed prior to August 2, 2013, but I am making a point).  Also, now we have 16 unmanaged outpatient behavioral therapy visits for children, whereas a couple of years ago we had 26 unmanaged visits.

The point is that when PCG or HMS audits your particular service, the auditors are not always experts in your particular service, nor experts in your particular service’s Clinical Coverage Policy.  See my blog on Dental Audits Gone Awry.  In this blog I show the required (or lack thereof) education/experience to become a PCG auditor.

Therefore, it is imperative that you have access to the applicable Clinical Coverage Policy applicable for the DOS audited.

But, if you google 2009 clinical policy for NC Medicaid dental services, you can’t find it.

So how are you supposed to get access to these old policies that are being used (or mistakenly NOT being used) in Medicaid audits for the older DOS?

It is called: The Way Back Machine.

I know, cheesy!  But I did not name it.

The “Way Back Machine” website looks like this:

Way Back Machine

The beauty of the “Way Back Machine” is that you can go to any current website.  Copy the internet address.  Paste that internet address into the “Way Back Machine” where you see “Way Back Machine” and a white box appears in which to type the website address. Type in the address, and hit the button “Take Me Back.” VOILA…time travel!!!!

Small Tip: I have found that if I use the internet address for the specific policy for which I am researching, I am less successful than if I use the general DMA Policy address found here.  Once you get to the appropriate year on DMA’s general policy website, you can click on the specific policy in which you are interested.

Using the “Way Back Machine,” you can go to the DMA Clinical Policy (for whatever Medicaid service) applicable years ago.

You should never need to go more than 3 years back, as Recovery Audit Contractors (RACs) without permission by DHHS, cannot audit DOS more than three years ago.

But, you need to review the Clinical Policy for [fill-in-the-blank] Medicaid service 2 years ago? No problem! Use the “Way Back Machine” and travel back in time.

Wouldn’t it be great if we could travel back in time “for real?” Prior to RACS…prior to PCG…prior to HMS….? We need a “Way Back Machine” for Medicaid providers (and me) “for real!”

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.


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?

Medicaid Provider Tip: How to Read a Claim Audit Finding

Claim Audit Findings (CAF).  It even sounds scary. Not to mention, if you receive a CAF, it means that you have been audited by the State or an agent thereof (which, in it of itself, is a scary process). So seeing a CAF does not make you happy. But it helps if you understand what the CAF is and, more importantly, is NOT telling you.

Here is what a CAF looks like:


This particular CAF was drafted more recently (the review was conducted March 2012, but this CAF was not drafted until much later).  I have seen earlier CAFs handwritten.

For the sake of this example, we are reviewing a CAF for 16 units billed for Community Support Team. Regardless of the type of health care service, the CAF will be on an identical form or very similar.

At the top of the CAF, you have all the information you need to pull the particular file to compare your file to the CAF.  The Medicaid recipient’s name, date of birth, and Medicaid number is listed.  Most importantly, the date of service (DOS) is listed.  No matter how many times you provided services to this recipient, the DOS on the CAF is the only DOS that matters.  However, word of caution, most of the time, you will receive 2-10 CAFs for one particular client for 2-10 DOS.  All the DOS matter in that case.

Moving to the middle section of the CAF, you can see on the left side, the CAF reads either “administrative” or “clinical.”  The middle of the middle (nice explanation, huh?) has a question.  Then the right side (of the middle section) has “Not Met/No,” or “Yes/Met,” etc.

I will go through each type of administrative or clinical topic.  The bottom of the CAF supposedly details more specifics about each topic.  Although I will show you how unhelpful the explanations are. In fact, the only helpful part of the bottom section is the fact that it shows you which year’s Clinical Policy the auditor used (as in which date. Since the policies have been revised so many times, the auditor frequently uses the incorrect policy.  It is important to have the policy in front of you that was in place for the particular DOS).

Ok, the topics on the CAF (the middle section of the CAF).  The topics are divided between administrative and clinical.  Administrative issues are (seemingly) objective; are the documents in the file? Clinical issues are more subjective, such as was there a demonstration of medical necessity and were the service notes adequately written (apparently these auditors believe that every provider should also be an ametuer novelist).

Let’s go through the administrative topics.

A1: Authorizations

“Is there an authorization in place covering this date of service?”  This is just a matter of did the Medicaid auditor review an authorization in the file at the time he or she reviewed the file.  Even if you had a valid authorization in place at the DOS, if  the auditor did not see the authorization in the file ate the time of the audit, you will receive a “Not Met” for A1.  

(“Not met” means you failed that particular facet of the audit and you will need to repay the amount received for the service.)

Another reason I have seen “Not Met” under A1 is for services that do not require authorizations.  The auditors apparently cannot figure out which services require authorizations and which do not.

A2: Service Orders:

“Is there a valid service order for the service billed?”  Again, the auditor looks in the file for a service order for the code billed.   The “Not Mets” I have seen for service orders range from the signature on the service order being illegible; therefore, the credentials of the signator could not be assessed to the service order ordering one CPT code, while the service was a different CPT code.  

A3: Person-Centered Plan (PCP)

“Is there a valid PCP in place for the date of service billed?”  Now, obviously, PCPs are used in Community  Support Team (CST), but not in all areas of health care, not even in all areas of behavioral health.  Nonetheless, I have seen CAFs require a PCP, even when a PCP is not required for particular service.  I’ve also seen CAFs that read “treatment plan/PCP,” but the CAF will not inform you for which (a treatment plan or PCP) the auditor has been told to look. Many “Not Mets” are because of the confusion on the part of the auditors as to what documentation is actually required for a service.

A4: Staffing Requirements:

“Does the team meet staffing requirements per the service definition?”  For A4, the auditors will actually look beyond the file (usually). As the onset of an audit you will be required to provide the auditor with all your staff’s credentials.  Beware: Many, many times I have a “Not Met” for A4 because the auditor could not read the signature; therefore, the auditor could not determine which staff member rendered services, much less whether the staff member met all required credentials.  But the auditor will not ask you whose signature is on the document; apparently, there is some rule somewhere in the world according to Medicaid auditors that signatures must be legible, because I sure as heck have not seen that rule.

A5: Staff Qualifications:

“Is there documentation that the staff is qualified to provide the service billed?”  This is a tad different from A4.  In A4, the governing criteria is the DMA Clinical Policy (whichever is applicable to the services you provide).  A5 is more specific.  If the staff member is providing substance abuse prevention, does the staff have the credentials showing that he or she is certified to provide substance abuse services.  The qualifications required depends on the service provided.

A6:Health Care Public Registry

“Did the provider agency complete a Health Care Public Registry check on any unlicensed staff providing the service billed prior to the date of service?”  Just as it reads, A6 requires the provider agency to complete a Health Care Public Registry for any unlicensed staff.  Here, the auditor will look for a piece of paper proving that the Registry check was conducted prior to the date of service.  But like most other topics, the auditor will not simply ask you whether you have completed a Registry check if the Registry check is not easily found, such as filed in the individual staff member’s file, not multiple copies filed with every single recipient who receives services from that staff member.  You will just receive a “Not Met.”

A7: Disclosure of Criminal Convictions

“Did the provider agency require disclosure of criminal convictions by staff person(s) who provided the service?”  A7 is so poorly drafted.  My high school English teacher would be appalled.  This is a classic example of a sentence in the English language not doing its job (which is to communicate).  Does the provider have to show the auditor that the provider has a written rule/policy that all staff members are required to disclose any criminal convictions? Or is the auditor actually looking for a criminal background check of all staff? A7 gives no guidance.  If you go down to A7 in the bottom section (that we will talk about later) you see that no further guidance is given.  So, you will just have to hold your breath in anticipation as to the answer until I get to the bottom section explanations.

C8: Entrance Criteria

“Does the Comprehensive Clinical Assessment support entrance criteria, per the service definition?”  C8 is the topic at which my blood begins to boil. Essentially, C8 is asking whether the Medicaid recipient meets entrance criteria for the service provided.  Mind you, providers (unless prior authorization is not required for the specific service) cannot bill for a service unless there is prior authorization from DMA (or, more specifically, the contracted company that was reviewing prior authorization for the state…it was ValueOptions for behavioral health).  So these auditors are reviewing services for recipients for which the provider already received prior authorization (meaning entrance criteria was met) from DMA or its acting agent and now, another contracted company, sometimes years later, is saying, “Hold on there. I know you already received prior authorization for this service, but in my subjective opinion, I disagree. I don’t think medical  necessity was met; entrance criteria was not met.” I don’t know how many due process or fundamental fairness rules C8 violates, but, so far, C8 is still part of the Medicaid audits.

C9: Individualized PCP

“Is the PCP individualized for the person?” Remember, above I wrote that sometimes, for different services, C9 will read treatment plan/PCP.  Regardless, if prior authorization is required for the service, the PCP was already reviewed before prior authorization was given.  See argument for C8.

C10: Crisis Plan

“Does the Crisis Plan include the required elements per the PCP Instruction Manual?” Again, C10 may change depending on the service.  But, regardless, if prior authorization is required for the service, the PCP, including the Crisis Plan, was already reviewed before prior authorization was given.  See argument for C8.

C11: Timeframe of Signature

“Is the documentation signed by the person who provided the service within the designated timeframe?”  This may be one of my favorites. Because you do not necessarily submit service notes for reimbursement daily, there are times that you submit multiple claims on one day.  Maybe you have an electronic service note system that you draft all service notes then sign them all as you submit them. (This is only one example of many of the nonsensical results of C11). The auditors will claim that you must sign all service notes on the DOS.  You will be told your service note is out of compliance if the dates of signature and service do not match. But my question is out of compliance with what? With the utopian laws of providing health care services? Certainly not out of compliance with the DMA clinical policy (that I have seen) or the Basic Medicaid Billing Guide.  Nothing that I have seen states that providers must sign the service notes on the date the service was provided.  The policies state the service notes must have the DOS and must be signed. Period.

C12: Billed Units

“Does the documentation support the units billed?”  For this topic, the auditors are looking at the service note and trying to locate a “time in” and “time out.”  Or a duration period noted on the service note.  The issue with C12 that I have seen is that some CPT codes, not all, but some, have, in the very definition, the duration specified. For example, in Outpatient Behavioral Health services, 90834 (now) denotes 38-52 minutes of psychotherapy. Before January 2013, 90804 denoted 25-30 minutes of individualized therapy.  If the definition of the CPT code defines the duration, why is there an additional requirement to physically write the time in and out on the service note? Apparently, the auditors know of a reason.

C13: Goals on PCP

“Does the service note relate to the goals in the PCP?” Again, C13 may change depending on the service.  But, regardless, C 13 is asking whether the treatment plan or the medical objectives for the patient are germane to the activities on the service note.  This is such a subjective determination.  However, I’ve had auditors deem no germaneness when a goal for the recipient is improving relationships with non-family members, and the service note denotes that the therapeutic treatment was role-playing as if the therapist was a non-family member. Hmm. Germane?

C14: Assessment of Progress

“Does the service note reflect assessment of progress toward goals?”  C14 is similar to C13 as to its subjectiveness.  Here, I have had auditors determine “Not Met” for C14 when the service note stated that the recipient is improving, but scared of consequences of result. Hmmm. Assessed progress?

C15: Individualized Interventions

“Are the interventions in the service note individualized per person and reflective of the service definition?”  What? How are services for a specific individual not “individualized?” What the auditors are not telling you in C15 is that the auditors are looking for service notes that appear to “cut and pasted” from prior service notes with minimal changes.  Apparently the auditors believe that if you provide one hour of therapy to a Medicaid recipients that that specific goal was met and that at next therapy session you can move on to the next goal.  Apparently, you do not have to work on one goal more than once.

A16: Unit Conformity

“Do the units documented match the units paid?” This is an administrative topic, but basically, mirrors C12.

Ok, there are the topics and my 2 cents worth on them.

Going to the bottom section of the CAF, I believe I discussed most of the issues in the bottom while I was describing the middle section. 

But for example, in bottom section C7 (of which you have so calmly awaited the explanation), “no employee information” submitted means (in auditor language) the auditor did not see a criminal background check prior to DOS.  wouldn’t it be so much easier if the explanations found in the bottom section actually stated what document was actually needed?

Or, for example, in bottom section A5, the auditor may not necessarily be saying that no staff information was provided.  A5 may actually mean that either (1) the auditor could not read the staff’s signature; and, therefore, the auditor could not determine whether the qualifications had been submitted; or (2) the service note was not in the file at the time the auditor reviewed the file, so the auditor cannot determine which staff member conducted the service.  But it is up to you to decipher.

Or, for example, in bottom section C8, when the auditor writes that no documentation submitted to show entrance criteria was met, the auditor is actually saying that, at the time the auditor reviewed the file, the file did not contain either an assessment or initial intake or referral or something to show the diagnoses of the patient.  However, it is interesting to note that during the audit of the file, if a provider tries to supplement the file with documents for which he or she knows the auditor is looking, the auditor refuses, saying that he or she can only review the file.  But C8 can mean that, in the subjective opinion of the auditor, that the documentation provided does not meet entrance criteria, or it can mean that the auditor does not have a full understanding of the entrance criteria, or it can mean that a documents proving entrance criteria was accidentally misdated.  C8 can mean a plethora of different scenarios; none of which are explained in the “explanation” of C8.

So, there you go, Claim Audit Findings 101.  Surely, you have no questions; it’s so easy!!

Regardless, appeal, appeal, appeal.

DMA Says, “It Wasn’t Me.”

Call up DMA. Ask about an issue. I bet DMA will pass the buck.  I call this the “It’s not me” disease.  Apparently, DMA has been infected.

Today I had a reconsideration review at the Division of Medical Assistance (DMA). This was a case in which DMA claimed my client was overpaid with Medicaid funds because of alleged documentation errors. My client was audited May of last year, never heard any results, then almost a year later, received a Tentative Notice of Overpayment stating that he owed DMA X dollars.  He came to me and we appealed the Notice.

For the most part, today’s reconsideration review was similar to past reconsideration reviews:

  • DMA cited my client for not having prior authorization when prior authorization was not required under DMA Clinical Policy 8C (Prior to January 1, 2012, the first 26 visits with a child were unmanaged in Outpatient Behavioral Therapy (OBT), thus not requiring prior authorization);
  • DMA cited my client for inappropriate referrals when the Medicaid recipient was an adult (Adults can self-refer for OBT);
  • DMA cited my client for failure to produce assessments when assessments were not required;

All that was normal. As usual, my client was cited for reasons inconsistent with Medicaid policy and regulations.

DMA’s inability to audit a health care provider in accordance to Medicaid policy and regulations was not why today’s reconsideration review was odd.

No, today was odd because the person DMA sent to represent DMA was a woman who did not conduct the audit, had never reviewed the audit findings until sitting in the reconsideration review, was completely unprepared and was, obviously, confused by the entire process of a reconsideration review.

DMA’s rep (we will call her Jane) introduced herself to me as a “DMA Hearing Specialist.” What? What is that?? I asked whether this was a new position, to which she responded, “Yes,” and informed me that she was only hired by DMA last August. I asked whether there were other “DMA Hearing Specialists.”  She told me there were 3 others. This was news to me.  I had never heard of a “DMA Hearing Specialist.”  But in my head, I thought, “Good. A specialist. At least she will know what is going on.”

Wrong again.

We went to the first Medicaid recipient at issue. (This was a recipient who was not my client’s client.  For reasons not important here, it was mis-billed, and my client had already returned the money to the appropriate provider). Jane, however, had not been informed of this detail.  First she stated that my client had provided all the required documents because under the section, “Reasons for Denial,” “ABCDEFG” was marked (meaning every reason provided was marked.) So the hearing officer asked whether this meant there was no issue for this recipient. Jane said “I guess so,” and “Maybe.”

Once the hearing officer asked again, Jane finally said, “Oh, never mind, the ABCDEFG means that no documents were provided. We needed everything.”

Once we cleared up that ambiguity, we informed the hearing officer that this recipient was not a client of my clients and that the money had been returned.

Now, it is important to note that at the beginning of the reconsideration review, Jane produced a summary of all claims findings from my client’s audit, as well as, a detailed explanation of all denials. Shocked, I requested copies (because my client had received zero information as to what the document deficiencies were prior to the reconsideration review).

In the summary (that we had not received until the date of the reconsideration review), on page 3, first paragraph, there was a detailed description about the auditor speaking to my client about the mis-billing, his subsequent return of the Medicaid funds, and the auditor’s review of financial information proving the fact that my client had returned the funds.  That audit occurred May 2012.  Now, today, we sat in the reconsideration review (March 2013) and my client was being cited for the very same issue that he proved in May 2012.  In other words, despite my client’s explaining the situation to the auditor and providing financial records to prove that he returned the funds, he STILL sat there today and had to explain it again and had been cited for the very reason he already proved.

When I asked Jane why we were still discussing an issue that had been resolved almost a year ago, she told that she did not conduct the audit.  She was just told to come to this reconsideration review and she was not to blame. (It was someone else at DMA). Why was that “someone else” not attending the reconsideration review?

The “it wasn’t me” theme is WAY too prevalent at DMA. When someone complains about a Managed Care Organization (MCO), DMA says, “It wasn’t me.” When an audit is incorrectly conducted DMA says, “It wasn’t me; it was the company we hired.”

“It wasn’t me” gets us nowhere.

DMA is in charge of North Carolina Medicaid.  Yet every time DMA is questioned about Medicaid issues,, “It wasn’t THEM.” Who was it?

If “someone” makes a decision at DMA, that “someone” should attend the reconsideration review to defend that “someone’s” action. “It’s not me” means “I understand that you’ve been accused of wrongdoing; I understand that your company is financially in stress because of “someone’s” determination that you have committed wrongdoing, I understand that your Medicaid recipients may not have a health care provider because of “someone’s”determination, but DMA decided that that “someone” does not need to be accountable. Instead DMA will send “another someone” with zero information, hat way, the “someone” to blame is NOT DMA.”

It wasn’t me.


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.

A Personal Account of a Medicaid Audit

Readers: I did not write the following blog.  A gentleman emailed me his personal account of a health care provider undergoing a Medicaid audit.  I asked for his permission to publish it and it was granted. (I apologize for any formatting issues.)

NOTE:  The following is somewhat long but is a reflection of the recent topsy-turvy, sinusoidal, and duplicitous events in the NC Outpatient Mental Health setting…….

During the summer of 2012, while I was standing outside of a clinic where I contract waiting for my next client, a car rapidly pulled up and out jumped 4 stony faced people with briefcases and a purpose in their steps as they entered the clinic

It was an unannounced Medicaid audit.

Many clinicians and agencies knew these were occurring so it was not completely unexpected.  At this particular free-standing private clinic which accepted Medicaid there was some anxiety (as any audit would produce) but we were pretty confident about our work – electronic medical records had fail safes for compliance, supervision occurred regularly, and the Clinical Coverage Policies for Medicaid were followed.

Over the next few months as the audit progressed a surrealistic Russian style bureaucratic nightmare occurred.  Medical records were requested by the auditors and submitted by the clinic.  CCME (Carolina Center for Medicaid Excellence) who was doing the audit would say ‘we didn’t get the records’ and be elusive and dodgy.  Medical records were re-submitted – hand delivered.  Feedback from CCME was that the Treatment Plans did not meet standards.  The Treatment Plans were being developed in line with the posted Clinical Coverage Policy and they were also in line with the recommendations of one of the LME/MCO’s right over the county border but after much back and forth CCME continued to say they were not in compliance.  CCME did not provide a clear indication of what compliance was nor did they provide a clear template for the Treatment Plans.  (NOTE: The LME/MCO from the nearby county said the clinic’s Medical Records per their site review were at a 92.5% accuracy!!!)

Staff at the clinic worked diligently to cooperate with CCME but every attempt at cooperation was met with a shift of the carrot on the stick.  Conference calls were scheduled, emails were written, repetitive requests for clarification were pursued without any success or resolve.

The clinic was then put on a “pre-payment review” meaning claims for services rendered were not paid until the records were reviewed and approved.  ‘Pre-payment review’ is an unguided process that could take 30 days – the approval of records is based on unclear standards so any clinical services rendered were like the lottery – maybe they’ll get reimbursed if someone somewhere says documents meet some kind of unknown standards….or maybe they won’t get reimbursed at all.

Eventually, so much unproductive hoop jumping occurred and time was wasted that a deadline for acceptance by the local LME/MCO came due.  Because of the delays by the CCME, the LME/MCO which went live on 2/1/13 said to the clinic ‘we can’t enroll you’ due to the ‘pre-payment’ status.

With only 3 days of lead time, over 100 clients – some of which were children in foster care or with PTSD or within the Juvenile Justice System – had to suddenly be terminated from treatment and referred to other agencies.  Fortunately, the clinic will continue – contracted with the other county LME/MCO and accepting private insurance.

Was this top-down inefficient State bureaucracy?  Was this effective Public Mental Health policy?  Was there any consideration for how this would impact service provision and the clients? Was this purposeful – intended sabotaging of a clinic in order to reduce the number of providers within a community and save Medicaid dollars?  Is this the CCME’s way of insuring ‘Excellence?’

I, and my colleagues who provide Public Mental Health services and who have weathered many pressures and changes, are not naive about accountability – we are ready to stand accountable and provide appropriate services with appropriate billing and documentation. I understand there are economic pressures at hand here but the current zeitgeist of audits, regulations and site reviews seems like a witch hunt and feels like a displacement for the past sins of others (  With the laser beam aimed at service providers – purposely geared to finding the smallest of errors in an effort to go ‘GOTCHA’ the zeitgeist is a culture of fear in order to insure accountability to DMA, CCME, DHHS, CMS, EDS, and the LME/MCO.  Well what about accountability to our clients?  Have policy makers forgotten about the clients in an effort to weed out the service provider playing field?

As a side note, it was rumored –  and it may just be urban legend – that Medicaid auditors were paid based upon how much money they generated from the audit. If anyone has more information on this I would love to hear it – but at the community level it is understood that the contracted auditors were paid based upon how much money they were able to save Medicaid – how many claim denials they could find and how much money they were able to claw-back.

Wouldn’t this contractual arrangement be considered a kickback?….’the more money you save or make us the more you will get from us?’  Aren’t kickbacks considered illegal within the Medicaid and Medicare system?

Clinicians, Clinics and Agencies believe that there has been an INTENDED consequence with the tightening of regulations (such as CABHA and Medicaid Waiver) – the intention is the eventual reduction of the number of private agencies that provide outpatient Mental Healthcare. Both, agencies that do enhanced services as well as core services, are being purposely circuitously and indirectly liquidated.  When looking at lists of agencies that accept Medicaid over time, there was a 50% reduction of agencies after CABHA.  With the implementation of the Medicaid Waiver the list has dwindled even further.  Initially LME/MCO’s have been accepting virtually all agencies that apply but it is anticipated that over the next year the bonsai tree will be trimmed even further with reviews of ‘outcome measures.’  More and more agencies will not be able to sustain.  It is presumed that the final goal is to have a few large agencies contracted across the state.

Now, be advised that I have seen with my own eyes heinous service and billing improprieties in 2005 and 2006 and received backlash from profiteers when I called out inappropriate activities….so, I agree that it is necessary to set clear standards and hold providers accountable…HOWEVER, the zeitgeist is an over-rotation.

Let’s see how the pendulum swing, tightening of the noose and reduction of reimbursements is working….

One of the larger agencies that has satellite offices in 15 counties in the central NC area just closed two of it’s offices in 2 counties.  In a different county where this large agency still has an office the pay for clinicians was cut, then cut again, then cut again, and a colleague of mine who works at this agency said that there were sweeping layoffis in her office.  What is interesting is that many community clinicians believed this big multi county agency was one of the golden children that would sustain and still be standing while all the other ‘mom and pop’ or ‘pop up’ agencies were dissolved.  Well, it seems like no one is immune anymore.

Another colleague of mine described how his multi county agency had radical re-structuring recently, specific Medicaid services were cut and the providers of those services were laid off, and there were across the board pay cuts.

Clinicians have no recourse either – ‘if you don’t like the pay cut then you can always try to find another job…wait…there are no other jobs since everyone else is closing so I guess you are stuck.’

On another side note, I recently head about a survey of private Psychologists who had been accepting Medicaid.  The survey showed that over 40% of them intended to stop taking Medicaid clients due to the increase of regulations and requirements and reduction of reimbursements (all of which makes service provision cost and time prohibitive).  Many of these surveyed Psychologists had over 8 years of experience – the intended consequence of reducing providers ALSO reduces your qualified and experienced professional base – these are the providers who know the clients and know the community and know the collateral resources.

I am aware of several private multi-county/multi-provider agencies that used to accept Medicaid clients but have stopped due to the cuts in rates and arduous regulations.  What is interesting is that these private non-CABHA agencies provide excellent care, are preferred by clients, and ironically they bill a FRACTION of what CABHA agencies bill.

On February 1st a therapist from NC had an ‘opinion’ published in the Washington Post called:

“The risk of skimping on mental health funding”

 Below is the link to this article which describes his frustrations with the Medicaid cuts in Southern Pines:

Since you may have to do a free ‘Register’ with the Washington Post online to see the article, here is an excerpt:

For mental health providers in North Carolina, 2013 marks another year of cuts to Medicaid reimbursement rates, which have declined steadily since 2008. States are responsible for a larger portion of mental health services than they are for physical services, which means mental health is hit hard by state budget negotiations. More than $4.3 billionhas been slashed from state mental health budgets nationwide since 2009, according to theNational Association of State Mental Health Program DirectorsSouth Carolina, Alabama, Alaska, Illinois and Nevada are among the states that have had the deepest cuts.

The director of our clinic in Southern Pines, N.C., in the center of the state, has told me that this year’s cuts are likely to force us to close. Our facility offers mental-health and substance-abuse counseling to 75 to 100 clients a week, half of whom are 18 years old or younger. Typically, they are referred to us from child protective services, doctor’s offices or the local domestic violence/sexual assault agency.

When the events at the service delivery level are brought to policy makers’ attention, I deeply resent their disregarding platitude of “oh well….we know change is hard.”  Well, it has been change (2001 divestiture and privatization), and change (2005 slashing community support), and change (2006 ValueOptions authorization policy changes) and change (2010 CABHA), and change (2012 Medicaid Waiver) and change (new billing and authorization systems such as Alpha and Provider Direct) and change (2013 Medicaid rates rates slashed 40% effective 1/1/13 then returned to prior rate on 1/23/13 with delays of payment for 1/13) and change (2013 CPT code changes and Medicaid rate and service time reductions)….You don’t know how many times I have had to say to clients “….I am sorry but there are NEW Medicaid regulations which will effect you in the following way…”  You don’t know how many of my colleagues have said to me “….the agency where I was working closed….do you know who is hiring….”).

Furthermore, I resent the proverbial ‘pot calling the kettle black’ when Community Agencies, Individual Clinicians, and Private Practices accepting Medicaid are being scrutinized and audited to the point of being inoperable ALL THE WHILE there is waste and mismanagement at the top – DMA mismanagement (, cost over runs with Computer Sciences Corporation (, “structural flaws,” and more (

I hope McCrory means what he says ( “We want to make sure that the money that’s supposed to help people is going to them, not to the administrative cost.”) and that ‘Medicaid Reform’ will have a positive result.  I hate to be a ‘Negative Nick,’ but my fear (based on experience) is that if you squeeze on one side of the tube of toothpaste it gets smooshed (yes…a real word) to the other side….in other words, the ATTEMPT to reduce administrative waste may actually make its way down to the community level in the form of service and provider cuts.   We shall see…..

I continue to provide services to Medicaid clients and IPRS clients through contracts with agencies, but it is unclear if I will be regulated out of the field.  The Waiver continues….

Feel free to write back with your experiences, thoughts, and or comments.

Geoffrey Zeger, ACSW, LCSW



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.”

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.


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.