Category Archives: NC Medicaid Bulletin
My mom taught me a song when I was young called, “A Hole in the Bucket.” It is a maddening song about a lazy husband named Henry who begins the song telling his wife Liza that “There’s a hole in the bucket, dear Liza, dear Liza….” To which Liza sings, “Then fix it, dear Henry, dear Henry…”
The song continues with Henry singing excuses and impediments to his ability to fix the hole in the bucket and Liza explaining to Henry how to overcome these excuses. The song goes around and around until, in order to fix the bucket, Henry would have to sharpen an ax on a stone that “is too dry,” and the only way to wet the stone is with the bucket that has a hole. “There’s a hole in the bucket…” And the songs starts anew and can be sung continuously, never-ending.
My husband and daughter audibly groan when I begin such song.
And you can’t blame them! It is discouraging and frustrating when something is caught in a never-ending circle with no end and no conclusion. It is human nature to try to resolve issues; it is also ingrained in Americans’ minds that hard work yields results. When hard work yields nothing but a big, fat goose-egg, it is exacerbating.
Kind of like claims in NCTracks…
When NCTracks went live on July 1, 2013, providers immediately began to complain the claims were being erroneously denied and they were receiving no reimbursements. Folks with whom I spoke with were at their wits-ends, spending hours upon hours trying to discern why claims were being denied and what process they could undertake to fix “the hole in the bucket.”
The problem persisted so long and I was contacted by so many providers that I instigated the NCTracks class action lawsuit, which is still pending on appeal, to the best of my knowledge, at my former firm. Although it was dismissed at the Business Court level, I believe it is on appeal. See blog.
Providers complained that, when they contacted CSC’s Help Desk regarding denied claims, the customer service representatives would have little to no understanding of the claims process and instruct them to re-file the denied claims, which created a perpetual cycle of unadjudicated claims.
“It was infuriating!” One provider explained. “It was as if we were caught in the spin cycle with no hope of stopping. I wanted to yell, ‘I’m dry all ready!!'”
“I was spending 20+ a week on NCTracks billing problems,” another said.
To which, I said, “There’s a hole in the bucket, dear Liza, dear Liza.”
Over two years after the “go live” date, the Department has now (finally) informed providers that there is an informal reconsideration review process for denials from CSC.
The September 2015 Medicaid Bulletin states that:
“This article provides a detailed explanation of the N.C. Division of Medical Assistance (DMA) procedures for Informal Reconsideration Review of adverse claim actions (denials, disallowances and adjustments) made by its fiscal agent, CSC.”
The Bulletin provides a 30 day time period during which a provider can appeal a denied claim:
“Time Limit for Submission of Request
- A provider may request a reconsideration review within 30 calendar days from receipt of final notification of payment, payment denial, disallowances, payment adjustment, notice of program reimbursement and adjustments. If no request is received within the respective 30 calendar day period, DMA’s action will become final.”
(emphasis in original).
You must request reconsideration review within 30 calendar days of the final notification. BUT what exactly is “final notification?” The initial denial? The second denial after re-submitting? The third? Or, what if, your claim is pending…for months…is that a denial? When CSC tells you to re-submit, does the time frame in which to file a reconsideration review start over? Or do you have to appeal every single denial for every single claim, even if the claim is re-submitted and re-denied 10 times?
This new informal appeal process is as clear as mud.
Notice the penalty for NOT appealing within 30 days…”DMA’s action will become final.”
This means that, if you fail to appeal a denial within 30 days, then the claim is denied and you cannot request a reconsideration review. Theoretically, there is a legal argument that, once the “final decision” is rendered, even if it were rendered due to you failing to request a reconsideration review, you would have 60 days to appeal such final decision to the Office of Administrative Hearings (OAH). Although, acting as the Devil’s advocate, there is an argument that your failure to request a reconsideration review and taking the appeal straight to OAH is “failing to exhaust your administrative remedies.” See blog. Which could result in your appeal being dismissed for lack of jurisdiction. This goes to show you the importance of having your attorney involved at the earliest juncture, otherwise you could risk losing appeal rights.
Let’s think about the “time limit for submission of request” in a real-life hypothetical.
You keep receiving denials for dialysis claims for no apparent reason. You received 20 denials on September 4, 2015. You contact a CSC customer service representative on September 8, 2015, four days later, due to Labor Day weekend. The customer service representative instructs you to re-file the claims because you must include the initial date of treatment in order to have the claims processed and paid (which was not required with HP Enterprises’ system). Is this the “final notification?” It does not seem so, since you are allowed to re-submit…
You revise all 20 claims to include the first treatment date on the claim and re-submit them on September 9, 2015. Since you re-submitted prior to the September 10th cutoff, you expect payment by September 16, 2015, 12 days after the initial denial.
You receive your explanation of benefits (EOBs) and 5 claims were adjudicated and paid, while 15 were denied again.
You contact CSC customer service and the representative instructs you to re-submit the 15 claims. The rep does not know why the claims were denied, but she/he suggests that you review the claims and re-submit. After hours of investigative work, you believe that the claims were denied because the NPI number was wrong…or the incorrect address was processed…or…
You miss the September 17th cut-off because you were trying to figure out why these claims were denied. you submit them for payment for the September 29th checkwrite date (25 days after the initial denial).
At this point, if any claims are denied, you wouldn’t know until October 6th, 32 days after the initial denial.
In my scenario, when is the final adjudication?
If the answer is that the final adjudication is at the point that the provider tries all possible revisions to the claims and continues to re-submit the claims until he/she cannot come up with another way to re-submit, then there is never final adjudication. As in, the provider could continue various changes to the billing ad nauseam and re-submit…and re-submit…and re-submit…”There’s a hole in the bucket!”
If the answer is that the final adjudication is the initial denial, then, in my scenario, the provider would be required to appeal every single denial, even for the same claim and every time it is denied.
You can imagine the burden to the provider if my second scenario is correct. You may as well hire a full-time person whose only task is to appeal denied claims.
Regardless, this new “Informal Reconsideration Review” purports to create many more questions than answers.
So may rules are enacted with good intentions, but without the “real life” analysis. How will this actually affect providers?
“There’s a hole in the bucket, dear Liza, dear Liza.”
“Then fix it.”
Extrapolated audits are no fun, unless you work for a recovery audit contractor (RAC). You get a Tentative Notice of Overpayment (TNO) that says the auditor reviewed 100 dates of service (DOS), found an overpayment of $1,000, so you owe $1 million dollars. Oh, and please pay within 30 days or interest will accrue…
North Carolina’s 2nd recovery audit contractor (RAC) is ramping up. HMS had a slower start than Public Consulting Group (PCG); the Division of Medical Assistance originally announced that HMS would be conducting post-payment reviews last October 2012 in its Medicaid Bulletin. NC’s 1st RAC, PCG came charging out the gate. HMS has been a bit slower, but HMS is active now.
HMS is performing post-pay audits on inpatient and outpatient hospital claims, laboratory, specialized outpatient therapy, x-ray and long-term care claims reviews.
According to the December 2013 Medicaid Bulletin, the findings for the first group of automated lab reviews were released in early November 2013. Additional lab reviews are expected to be completed and findings released by late December 2013. The post-payment reviews are targeting excessive drug screening.
And specialized therapy service providers, you are next on the list!
How will the providers know the results of an HMS post-payment review? Same way as with PCG. You will receive a Tentative Notice of Overpayment (TNO) in the mail with some crazy, huge extrapolated amount that you supposedly owe back to the state.
If you receive a TNO, do not panic (too much), take a deep breath and read my blog: “You Received a Tentative Notice of Overpayment, Now What?”
Remember, most of the post-payment reviews that I have seen have numerous auditing mistakes on the part of the auditor, such as the auditor applying the more recent clinical coverage policies rather than the clinical coverage policy that was applicable to dates of services audited.
DMA Clinical Policy 1S-4 “Cytogenetic Studies“, for example, was recently revised February 1, 2013. Obviously, an auditor should not apply the February 1, 2013, policy to a service provided in 2012…but you would not believe how often that happens!
So what can you do to be prepared? Well, realistically, you cannot be prepared for audit ineptness.
But you can be proactive. Contact your insurance policy to determine whether your liability insurance covers attorneys’ fees for regulatory audits. It is important to be proactive and determine whether your insurance company will cover attorneys’ fees prior to undergoing an audit. Because if you find out that your liability insurance does not cover attorneys’ fees, then you can upgrade your insurance to cover attorneys’ fees. I promise, it is way better to pay additional premiums than get hit with $25,000+ bill of attorneys’ fees. Plus, if you wait until you are audited to determine whether your liability insurance covers attorneys’ fees and you realize it does not, then the insurance company may not allow you to upgrade your insurance. The audit may be considered a pre-existing condition.
So…proactiveness is imperative. But you can always move to West Virginia…
In a survey of 18 states conducted by the National Conference of State Legislatures (NCSL) and published August 29, 2013, NCSL determined that 10 states use extrapolations with the RAC audits, 7 do not and 1 intends to use extrapolations in the future. (No idea why NCSL did not survey all 50 states).
Delaware, Maryland, New Hampshire, Pennsylvania, Vermont, West Virginia, and Wisconsin do not use extrapolations in Medicaid RAC audits.
So moving to West Virginia is an option too…
It is without question that the implementation of NCTracks has been a complete debacle. NCTracks is the new computer system that is processing Medicaid claims for all health care providers who accept Medicaid in North Carolina. NCTracks went live July 1, 2013.
Immediately upon going “live,” providers received error messages. Providers were not timely paid. If the provider was paid, the reimbursement amount was incorrect. Depending on the type of provider you are, your issues varied from other types of providers. But all types of providers encountered adverse issues.
I still do not understand, even today, why the current administration did not stand up (figuratively and publicly) against Computer Sciences Corporation (CSC) the company contracted to create NCTracks and say, “North Carolina, CSC has created this debacle. We didn’t hire CSC. The past administration did. We will try to fix this debacle now…” That would have been the best public relations move, in my mind. However, instead, the Department of Health and Human Services (DHHS) stood by CSC and stated publicly how wonderful NCTracks was doing….”NCTracks is on track!”
Oh, well, suum cuique. Or…to each his own.
One of the biggest problems for providers with NCTracks is the Medicare/Medicaid crossover issue.
What is the Medicare/Medicaid crossover issue?
DHHS explains the crossover issue in the November 2013 Medicaid Bulletin as the “Medicaid Allowable minus Medicare Paid Amount equals the Net Medicaid Allowable. Next, the Net Medicaid Allowable is compared to the Medicare Coinsurance Amount and the lesser of the two is the amount payable by Medicaid.”
DMA also offers the following chart as clarification
|Example No. 1||Example No. 2|
|Total Billed Charges||
|Medicare Allowed Amount||
|Medicare Paid Amount||
|Medicare Contractual Adjustment||
|Medicare Coinsurance Amount||
|Medicare Paid Amount||
|Net Medicaid Allowable||
|Lesser of Medicare Coinsurance and Net Medicaid Allowable Amount||
DHHS goes on to say that even though the crossover claims should have been paid according to the above logic, the payments to providers for crossover claims on the NCTracks system versus the HP system may be different, as in, you may be getting paid less on the NCTracks system.
Why? We had the HP system for 35 years.
Well, according to DHHS, because the HP system “lacked the capability to perform such calculations on a claim specific basis. Instead, the prior Medicaid claims system included a “work around” that estimated the amount payable. In some cases, the “work around” paid more than the amount payable in accordance with State law and the North Carolina State Plan approved by CMS.”
Hold on….Hit the brakes!!!
Is DHHS telling us that NC was not federally compliant with Medicare/Medicaid crossover claims for 35 years???!!!!???
So, how much does NC owe to the federal government for overpaid crossover claims over a 35-year period?? And will it be extrapolated? Maybe PCG can audit NC.
This boggles my mind.
Here is the other fact that boggles my mind:
According to DHHS, “on October 7, 2013, NCTracks implemented system logic to more precisely pay Medicare crossover claims in accordance with State law and the North Carolina State Plan approved by the Centers for Medicare and Medicaid Services (CMS) on a claim specific basis. The amount of payment is the difference in the amount paid by Medicare and the Medicaid Allowable amount up to the actual amount of the Medicare coinsurance, deductible or both.”
98 days after NCTracks went live???
Why in the world would this Medicare crossover issue NOT be implemented PRIOR TO going live? The Medicare crossover issue just doesn’t seem to be a “Eh, whatever…Let’s take a gamble” issue.
So I propose a toast to DHHS. Well done. Well done on becoming federally compliant as to the Medicare/Medicaid crossover claims (if, in fact ,we are) 35 years later. And well done, to implementing a NCTracks implemented system to “more precisely pay Medicare crossover issues” 98 days after NCTracks went live.
To timeliness! Here! Here!! (the clinking of glasses).
Maybe…just maybe….in 200+ years, NC may fix the broken Medicaid system…