Category Archives: Local Management Entity
Given how long the Medicaid reform discussions have been going on at the legislature, you may be glazed over by now. Give me the memo when they pass something, right? Fair enough, let’s keep it brief. Where do things stand right now?
Last Wednesday, the Senate staked out its position in the ongoing debate between the House and the McCrory administration.
The Senate’s newest proposal is an unusual mix of different systems and new ideas. Not willing to commit to one model for the whole Medicaid program, the latest version of the bill includes something new called Provider Led Entities, or “PLEs.” PLEs are yet the latest in the alphabet soup of different alternatives to straight fee-for-service billing for Medicare/Medicaid. You’ve all heard of HMOs, PPOs, MCOs, and ACOs. PLEs appear to be similar to ACOs, but perhaps for political reasons the Senate bill sponsors saw the need to call the idea something different. See Knicole Emanuel’s blog.
In any event, as the name suggests, such organizations would be provider-led and would be operated through a capitated system for managing the costs of the Medicaid program. The Senate bill would result in up to twelve PLEs being awarded contracts on a regional basis.
PLEs are not the only addition to the Medicaid alphabet soup that the Senate is proposing in its version of HB 372. The Senate has also renewed its interest in taking Medicaid out of the hands of the N.C. Department of Health and Human Services entirely and creating a new state agency, the Department of Medicaid (“DOM”).
(One wonders whether the continual interest in creating a new Department of Medicaid independent of the N.C. Department of Health and Human Services had anything to do with embattled DHHS Secretary Wos stepping down recently.)
The Senate also proposes creating a Joint Legislative Oversight Committee on Medicaid (“LOC on Medicaid”).
But creating the DOM and using new PLEs to handle the provision of Medicaid services is not the whole story. Perhaps unwilling to jump entirely into a new delivery system managed by a wholly new state agency, the Senate bill would keep LME/MCOs for mental health services in place for at least another five years. Private contractor MCOs would also operate alongside the PLEs. The North Carolina Medicaid Choice coalition, a group which represents commercial MCOs in connection with the Medicaid reform process, is pleased.
One very interesting item that the Senate has included in its proposed legislation is the following requirement: “Small providers shall have an equal opportunity to participate in the provider networks established by commercial insurers and PLEs, and commercial insurers and PLEs shall apply economic and quality standards equally regardless of provider size or ownership.” You can thank Senator Joel Ford of Mecklenburg County for having sponsored this amendment to the Senate version of House Bill 372.
By pulling the Medicaid reform proposal out of the budget bill, the matter appears headed for further negotiation between the House and the Senate to see if the two can agree this year, unlike last year.
By legislative standards, that counts as forward progress… Here come the legislative discussion committees to hash it out more between the two chambers. We will keep a close eye on the proposals as they continue to evolve.
By Robert Shaw
Hey, everybody!! Anyone miss me? I feel like I haven’t blogged in forever. And, the thing is, I am so excited about this blog!! I actually found out about the CMS letter last week, but have had zero time to blog (had a very intense, two-day hearing). So I apologize if you have already seen the CMS letter…but, for others, read on…
I have to say…I love it when I am right!
In North Carolina, we set up managed care organizations (MCOs) to manage behavioral health care for Medicaid. For the past year, I have been blogging that the MCOs’ payment arrangement with the Department of Health and Human Services (DHHS) is fishy. These MCOs are pre-paid. Their profit hinges on spending less. In order to spend less, the MCOs deny medically necessary services (usually the most expensive) and terminate quality health care providers’ Medicaid contracts. I mean, come on, why authorize more services and contract with more providers if doing so would directly decrease your profit?
Apparently, I am not the only person concerned with how the MCOs are compensated.
On October 24, 2013, the Centers for Medicare and Medicaid Services (CMS), which is the federal agency charged with overseeing Medicare and Medicaid (as in, if CMS says jump and you accept federal money for Medicaid, you jump) sent correspondence to our Acting Medicaid Director Sandy Terrell. (Remember Carol Steckel abruptly left our Director position, leaving Terrell holding the conch…I bet that conch is getting mighty heavy!).
CMS’ correspondence states that, during its review of NC’s contracts between DHHS and the LME/MCOs, CMS determined an issue. Specifically, CMS determined that the arrangement between DHHS and the MCOs may be classified as “subgrants or intergovernmental agreements that are subject to the cost principles set forth in the Office of Management and Budget (OMB) Circular A-87 (A-87).”
So what? Who cares if the arrangement between the MCOs and DHHS is classified as a subgrant subject to A-87? Blah…blah….blah….right?
If the MCOs are subject to A-87, then the use of Medicaid funds is limited to “allowable costs.” Why is that important? Allowable costs do NOT include….
PROFIT!!!!! and other increments above cost.
For a rant and rave about the MCOs’ profit, high salaries and expensive health care benefits, see my blog: “NC Taxpayers Demand Accountability as to Behavioral Health Care Medicaid Funds (And That Medicaid Recipients Reap the Benefit of Such Funds).
If you take away the ability for the MCOs to profit off of our taxpayers’ Medicaid money, then you take away the monetary incentive for the MCOs to deny medically necessary services and to terminate provider contracts.
Know what else you take away? The desire to be an MCO.
So what happens now? Just because CMS wrote a letter to NC saying it does not agree with our payment arrangement with the MCOs, does that mean that we have to immediately stop and desist from paying the MCOs? No.
In fact, CMS also states that it “recognize[s] that changing a long-standing delivery system will take time and potentially state legislation. We know the process begins with a frank discussion of these issues…”
CMS did, however, provide a couple of choices for us (if, in fact, A-87 does apply):
1. Openly procuring behavioral health services and making the counties compete on the same basis as with any other commercial entity; or
2. Comply with A-87 by changing the payment methodology and reimburse only for the cost of services actually rendered plus administration costs.
I am actually doing the Snoopy dance as you read this.
Herein lies the problem…How many times in the last 10 years, has NC changed the mental health care system? How many mess-ups? How many Medicaid recipients have not received medically necessary mental health care service because of NC changing the mental health system over and over?
So what happens now?
On a sidenote, I love North Carolina’s response to CMS. Over a month after receipt of the CMS letter, on November 27, 2013, DHHS finally responds with a short, 2 paragraph letter signed by Sandy Terrell. “As you might expect, North Carolina was surprised to receive the letter outlining [CMS’] concerns regarding the cost principles set forth in the Office of Management and Budget (OMB) Circular A-87…”
NC was surprised???
I am reminded of Andrew Lloyd Webber’s “Evita,” when Eva Peron follows her lover to Buenos Aires only to discover he is married with children. She has all her belongings in a suitcase, turns from her ex-lover’s home and sings, “Another Suitcase in Another Hall.”
So what happens now
(Another suitcase in another hall)
So what happens now
(Take your picture off another wall)
Where am I going to
(You’ll get by you always have before)
Where am I going to
Just like Eva Peron, NC had full faith the MCOs, enacted them statewide, and, then, not even a year into the statewide MCO progam…BOOM! The MCOs are married with kids.
So what DOES happen now?
In the short-term, probably nothing. And, there is a chance that nothing happens in the long-term. In NC’s response, Ms. Terrell wrote that “[w]e believe we have information to share with CMS that should alleviate those concerns…”
Most likely, Ms. Terrell will explain to CMS how the wonderful MCOs are completely objective and how they save NC millions in Medicaid money…We will see whether CMS drinks DHHS’ Kool-Aid…
If, on the other hand, CMS demands change, in the long-term, there will be great change.
If we go with Door #1…”Openly procuring behavioral health services and making the counties compete on the same basis as with any other commercial entity,” what will that look like?
I believe CMS is envisioning not allowing the MCOs to monopolize their catchment areas.
Here are the MCOs “jurisdictions” today:
And more mergers are currently being contemplated. But, for now, if you live in Mecklenburg county and need behavioral health care services you must go through MeckLINK. Raleigh? Alliance is your MCO. You have no choice of MCOs and must use a provider within the MCO’s catchment area.
The way I understand CMS’ proposal, if you live in Mecklenburg county, you would not have to receive services from or (if you are a provider) have a contract with MeckLINK. You could, but there would other options as well. Door #1 is what I call, “Busting up the Baby Bells!”
What about Door #2? “Comply with A-87 by changing the payment methodology and reimburse only for the cost of services actually rendered plus administration costs.”
For this option, I believe, that the MCOs could remain where they are, but contract to be paid some, sort of, “cost-plus.” No more…if you do not spend it, it is your profit. Theoretically if the money were not spent, it would be returned to DHHS, or, somehow, kept for additional services. Bye, bye, monetary incentive to deny services and terminate providers!
Door #2 is what I call, “Busting up the Ponzi scheme!”
No matter which door NC chooses, it has to be better than our current situation with the MCOs.
Ok, I stopped doing the Snoopy dance.
Because, in reality, there will be change. We do not know what the changes will be. And, dag on it, change is scary, especially we are talking about changes to mental health services for Medicaid recipients.
As Eva Peron says, “Where [are we] going to?”
Then, if you have seen the motion picture “Evita,” Antonio Banderes sings, “Don’t ask anymore…”
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):
- Date of service;
- Name of the service provided (e.g., Outpatient Therapy – Individual/Family Tx);
- Type of contact (face-to-face, phone call, collateral); non-face-to-face services are not covered and not reimbursable;
- Purpose of the contact (tied to the specific goals in the Tx plan);
- 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;
- Effectiveness of the intervention(s) and the beneficiary’s response or progress toward goal(s);
- 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
- 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.
- 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.