Category Archives: Wyoming Medicaid

Want to Drop Medicaid? (And I Don’t Blame You), But Here Are a Few Issues to Contemplate First

Low reimbursement rates make accepting Medicaid seem like drinking castor oil. You wrinkle your nose and swallow quickly to avoid tasting it. But if you are a provider that does accept Medicaid and you wish to stop accepting Medicaid – read this blog and checklist (below) before taking any action! Personally, if you do accept Medicaid, I say, “Thank you.” See blog. With more and more Medicaid recipients, the demand for providers who accept Medicaid has catapulted.

The United States has become a Medicaid nation. Medicaid is the nation’s largest health insurance program, covering 74 million, or more than 1 in 5 Americans.

Earlier this year, Kaiser published a report stating that 70% of office-based providers accept new patients covered by Medicaid. But this report does not mean that Medicaid recipients have access to quality health care. I will explain below.

medicaidacceptance

The variation in the above chart is interesting. Reimbursement rates directly impact whether providers in the state accept Medicaid. The participation goes from a low of 38.7% in New Jersey (where primary care reimbursement rates are 48% of Medicare rates) to a high of 96.5% in Nebraska (where the primary care reimbursement is 75% of Medicare). Montana, with a 90% physician participation rate, pays the same rate as Medicare for primary care, while California, with a 54.2% participation rate, pays 42% of the Medicare reimbursement rate. We should all strive to be like Nebraska and Montana … granted the number of Medicaid recipients are fewer in those states. For September 2017, Nebraska ranked 45th out of the 50 states for Medicaid enrollment. Montana ranked 42nd. Wyoming came in dead last.

Statistically writing, Medicaid covers:

  • 39% of all children.
  • Nearly half of all births in the country.
  • 60% of nursing home and other long-term care expenses.
  • More than 1/4 of all spending on mental health services and over a fifth of all spending on substance abuse treatment.

However, even if the report is correct and 70% of health care providers do accept Medicaid, that is not indicative of quality access of care for Medicaid recipients. The number of Medicaid recipients is skyrocketing at a rate that cannot be covered by the number of providers who accept Medicaid. Kaiser estimates that by 2020, more than 25% (1 out of 4) of Americans will be dependent on Medicaid. Because of the low reimbursement rates, health care providers who do accept Medicaid are forced to increase the quantity of patients, which, logically, could decrease the quality … or the amount of time spent with each patient. Citing the percentage of providers who accept Medicaid, in this instance, 70%, is not indicative of quality of access of care; the ratio of Medicaid recipients to providers who accept Medicaid would be more germane to quality of access to care for Medicaid recipients. Even if 70% of health care providers accept Medicaid, but we have 74 million Medicaid recipients, then 70% is not enough. My opinion is what it is because based on years of experience with this blog and people reaching out to me. I have people contact me via this blog or email explaining that their mother, father, child, sister, or brother, has Medicaid and cannot find a provider for – dental, mental health, developmentally disabled services. So, maybe, just maybe, 70% is not good enough.

Before dropping Medicaid like a hot potato, ask yourself the following questions:

  1. Will I have enough patients without Medicaid to keep my staff and I busy?

Location! Location! Location! Your location matters. If you provide health care services in areas that are predominantly Medicaid-populated, then you may need to reconsider dropping the ‘Caid. California, New York, and Texas were the top spenders in Medicaid for fiscal year 2016, totaling over a whopping $183 billion of America’s total expenditure on ‘Caid, which was $553 billion.

I am sure that I am preaching to the choir, but choosing to not accept Medicaid is not fiscally sound if you and your staff will be twiddling their thumbs all day. Even low reimbursement rates are better than no reimbursement rates. On the downside, if you choose to accept Medicaid, you need a “rainy-day” fund to pay for attorneys to defend any regulatory audits, termination of Medicaid contracts, accusations of fraud, prepayment review, and/or other adverse determinations by the state (and, if you accept  Medicare, the federal government and all its vendors).

2. Have I attested for the Medicaid EHR meaningful use incentives?

If you attested and accepted the EHR incentive payments, you may need to continue seeing Medicaid patients in order to keep/maintain your EHR payments. (Please consult an attorney).

3. Will I still be subject to Medicaid audits in the future?

If avoiding Medicaid audits is your primary reason for dropping ‘Caid, ‘ho your horses. Refusing to accept ‘Caid going forward does not indemnify you from getting future audits. In fact, in cases of credible allegations of fraud, you may be subject to future Medicaid audits for another 6 years after you no longer accept Medicaid. You will also need to continue to maintain all your records for regulatory compliance. If you cease accepting Medicaid, those recipients will need to find new providers. Those medical records are the Medicaid recipients’ property and need to be forwarded to the new provider.

If you are currently under investigation for credible allegations of fraud, of which you may or may not be aware, then suddenly stop accepting Medicaid, it could be a red flag to an investigator. Not that ceasing to accept Medicaid is evidence of wrongdoing, but sometimes sudden change, regardless of the change, can spur curiosity in auditors. For example, in NC DHHS v. Parker Home Care, the Court of Appeals ruled that a tentative notice of overpayment by Public Consulting Group (PCG) does not constitute a final agency decision. The managed care organizations (MCOs) freaked out because the MCOs were frightened that a health care provider could argue, in Court, that Parker Home Care applies to MCOs, as well. They were so freaked out that they filed an Amicus Curiae Brief, which is a Brief on behalf of a person or organization that is not a party to a particular litigation but that is permitted by the court to advise it in respect to some matter of law that directly affects the case in question. The MCOs’ Brief states, “The Court of Appeals’ decision, if allowed to stand, could be construed to undermine the authority explicitly granted to managed care organizations, such as the LME/MCOs in North Carolina, by CMS.” Too bad our Waiver specifically states that DHS/DMA to CMS states, “[DMA] retains final decision-making authority on all waiver policies and requirements.” But I digress. In Parker Home Care, the MCOs filed the Brief to preserve their self-instilled authority over their catchments areas. However, despite the MCOs request that the NC Supreme Court take the issue under consideration, the Supreme Court denied certiorari, which means the Supreme Court refused to entertain the issue. While it is not “law” or “precedent” or “written in stone,” generally, attorneys argue that the Supreme Court’s refusal to entertain an issue means that it does not deem the issue to be a controversy … that the Court agrees with the lower court’s decision. Hence, the argument that the MCOs  cannot render final agency decisions.

4. Will I be able to sleep at night?

Health care providers become health care providers, generally, with the intent to help people. This makes most health care providers nurturing people. You have to ask yourself whether you will be comfortable, ethically, with your decision to not accept Medicaid. I cannot tell you how many of my clients tell me, at some point, “I’m just not going to accept Medicaid anymore.” And, then continue to accept Medicaid … because they are good people. It infuriates me when I am in court arguing that terminating a provider’s Medicaid contract will put the provider out of business, and the attorney from the State makes a comment like, “It was the provider’s business decision to depend this heavily on Medicaid.” No, actually, many providers do feel an ethical duty to serve the Medicaid population.

Check your health care community and determine whether other providers with your specialty accept Medicaid. Are they accepting new Medicaid patients? Are they viable options for your patients? Are they as good as you are? Just like attorneys, there are good and bad; experienced and inexperienced; intelligent and not-so-much; capable and not-so-much.

5. Can I delegate Medicaid recipients to a mid-level practitioner?

Physician assistants and nurse practitioners are wonderful assets to have to devote to Medicaid recipients. This is not to say that Medicaid recipients deserve lesser-educated services because, quite frankly, some PAs and NPs are just as good as the MDs. But you get my point. If PAs and NPs have a lower billable rate, then it makes business financial sense to delegate the Medicaid recipients to them. Similarly, I have an amazing, qualified paralegal, Todd Yoho. He has background in medical coding, went to two years of law school, and is smarter than many attorneys. I am blessed to have him. But the reality is that his billable rate is lower than mine. I try to use his services whenever possible to try to keep the attorneys’ fees lower. Same with mid-level practitioner versus using the MD.

6. Instead of eliminating Medicaid patients, can I just decrease my Medicaid patients?

This could be a compromise with yourself and your business. Having the right balance between Medicaid recipients and private pay, or even Medicare patients, can be key in increasing income and maintaining quality of care. Caveat: In most states, you are allowed to cap your Medicaid recipients. However, there are guidelines that you muts follow. Even Medicaid HMOs or MCOs could have different requirements for caps on Medicaid recipients. Again, seek legal advice.

All Medicare/Caid Health Care Professionals: Start Contracting with Qualified Translators to Comply with Section 1557 of the ACA!!

Being a health care professional who accepts Medicare and/ or Medicaid can sometimes feel like you are Sisyphus pushing the massive boulder up a hill, only to watch it roll down, over and over, with the same sequence continuing for eternity. Similarly, sometimes it can feel as though the government is the princess sleeping on 20 mattresses and you are the pea that is so small and insignificant, yet so annoying and disruptive to her sleep.

Well, effective immediately – that boulder has enlarged. And the princess has become even more sensitive.

boulder

On May 18, 2016, the Department of Health and Human Services (HHS) published a Final Rule to implement Section 1557 of the Affordable Care Act (ACA). Section 1557 of the ACA has been on the books since the ACA’s inception in 2010. However, not until 6 years later, did HSD finally implement regulations regarding Section 1557. 81 Fed. Reg. 31376.

The Final Rule became effective July 18, 2016. You are expected to be compliant with the rule’s notice requirements, specifically the posting of a nondiscrimination notice and statement and taglines within 90 days of the Final Rule – October 16, 2016. So you better giddy-up!!

First, what is Section 1557?

Section 1557 of the ACA provides that an individual shall not, on the basis of race, color, national origin, sex, age, or disability, be

  • excluded from participation in,
  • denied the benefits of, or
  • subjected to discrimination under

all health programs and activities that receive federal financial assistance through HHS, including Medicaid, most Medicare, student health plans, Basic Health Program, and CHIP funds; meaningful use payments (which sunset in 2018); the advance premium tax credits; and many other programs.

Section 1557 is extremely broad in scope. Because it is a federal regulation, it applies to all states and health care providers in all specialties, regardless the size of the practice and regardless the percentage of Medicare/caid the agency accepts.

HHS estimates that Section 1557 applies to approximately 900,000 physicians. HHS also estimates that the rule will cover 133,343 facilities, such as hospitals, home health agencies and nursing homes; 445,657 clinical laboratories; 1300 community health centers; 40 health professional training programs; Medicaid agencies in each state; and, at least, 180 insurers that offer qualified health plans.

So now that we understand Section 1557 is already effective and that it applies to almost all health care providers who accept Medicare/caid, what exactly is the burden placed on the providers? Not discriminating does not seem so hard a burden.

Section 1557 requires much more than simply not discriminating against your clients.

Section 1557 mandates that you will provide appropriate aids and services without charge and in a timely manner, including qualified interpreters, for people with disabilities and that you will provide language assistance including translated documents and oral interpretation free of charge and in a timely manner.

In other words, you have to provide written materials to your clients in their spoken language. To ease the burden of translating materials, you can find a sample notice and taglines for 64 languages on HHS’ website. See here. The other requirement is that you provide, for no cost to the client, a translator in a timely manner for your client’s spoken language.

In other words, you must have qualified translators “on call” for the most common 15, non-English languages in your state. You cannot rely on friends, family, or staff. You also cannot allow the child of your client to act as the interpreter. The clients in need of the interpreters are not expected to provide their own translators – the burden is on the provider. The language assistance must be provided in a “timely  manner. “Further, these “on call” translators must be “qualified,” as defined by the ACA.

I remember an English teacher in high school telling the class that there were two languages in North Carolina: English and bad English. Even if that were true back in 19XX, it is not true now.

Here is a chart depicting the number of non-English speakers in North Carolina in 1980 versus 2009-2011:

languages

As you can see, North Carolina has become infinitely more diverse in the last three decades.

And translators aren’t free. According to Costhelper Small Business,

Typical costs:
  • Interpreting may take place in person, over the phone or via video phone.
  • In-person interpreters typically cost $50-$145 per hour. For example, American Language Services offers interpreters starting at $100 per hour (or $125 for sign language) and a two-hour minimum is required.
  • Phone interpreters typically cost $1.25-$3 per minute. Language Translation, Inc. offers a flat fee of $1.88 per minute for phone interpreting, for example.
  • Video interpreters typically range from $1.75 to $7 per minute. For instance, LifeLinks offers video interpreting from $2.25 per minute for any language and $2.95 for sign language. A 15-minute minimum is common for phone or video interpreting.

It seems likely that telehealth may be the best option for health care providers considering the cost of in-person translations. Of course, you need to calculate the cost of the telehealth equipment and the savings you project over time to determine whether the investment in telehealth equipment is financially smart.

In addition to agencies having access to qualified translators, agencies with over 15 employees must designate a single employee who will be responsible for Section 1557 compliance and to adopt a grievance procedure for clients. Sometimes this may mean hiring a new employee to comply.

The Office of Civil Rights (“OCR”) at HHS is the enforcer of Section 1557. OCR has been enforcing Section 1557 since its inception in 2010 – to an extent.

However, expect a whole new policing of Section 1557 now that we have the Final Rule from HHS.

NC is #1 in USA!! (For Highest Percentage Increase in Total Medicaid Spending)…and What About the Rest of the USA?

On October 21, 2013, the magazine Modern Healthcare published an article, “Medicaid budgets By State,” which showed each state’s total Medicaid spent in 2012, total number of Medicaid enrollees in 2012, and average spending per enrollee in 2012.

Where does North Carolina rank in terms of our Medicaid budget versus other states?  We hear constantly that we spend all this needless money on administrative costs of Medicaid.  But, in terms of our Medicaid budget, where do we rank?  And my next question…do we simply have more Medicaid recipients in NC in relation to other states?  Is NC’s average spending per Medicaid enrollee grossly higher or lower than the national average?

Inquiring minds want to know!

Surprisingly, at least to me, Alaska has the highest average spending per Medicaid enrollee: $13,073, on average, per enrollee.  But then I thought about, much of Alaska is rural…not only rural , but almost impossible to navigate due to the snow and ice.  I don’t know for sure, but I would imagine that getting to and from Medicaid recipients or getting recipients to services (while not always reimbursed by Medicaid) must impact some of the costs.

[Important to note: The average spending per enrollee, to my knowledge, does not mean actual money spent per enrollee.  I believe the authors took the total budget and divided it by the number of enrollees.  So the average spent per enrollee includes built-in, administrative costs.]

Or…Maybe Alaska has a low number of Medicaid recipients and that is why Alaska spends the most per enrollee…maybe Alaska has a huge Medicaid budget without many recipients on which to spend it…few people, big pie…

I looked.

Alaska had, in 2012, 109,000 Medicaid recipients.

The fewer people you have at Thanksgiving, the bigger the pie pieces.  However, interestingly enough, Alaska spent $1.425 million total in Medicaid in 2012.  Delaware spent $1.421 in Medicaid in 2012. (Close enough, right?).  Yet, Delaware spent $6831, on average, per enrollee.  Maybe the pie analogy doesn’t work.  Maybe sometimes, even with a big pie and few people, too many rats and ants nibble at the pie.

Out of 50 states, where do you think NC falls?  Top 10 highest spender?  Bottom 10?  Right in the middle?

Drum roll……..

#9.

The only 8 states that spend more than NC per Medicaid recipient are:

1. Alaska

2.  New Jersey (somehow that did not surprise me) ($11,433/recipient)

3. Rhode Island (that did surprise me…I mean, look how little RI is…how big a Medicaid budget can it have?) ($11,080/recipient)

4.  North Dakota (a less populous state (less tax dollars), I believe) ($10,969/recipient)

5.  Pennsylvania ($10,835/recipient)

6.  Minnesota (there are big cities there (more tax dollars), no surprise) ($10,080/recipient)

7.  Missouri  (I went to law school in Missouri. This number surprised me a bit).  ($10,022/recipient)

8.  Connecticut ($9883/recipient)

9.  NC ($9,430/recipient)

Crazy! What about Illinois? With the hugely populous, Windy City and it being Obama’s home state, surely, Medicaid spending per recipient is, at least, in the middle, right?

Wrong.  Illinois is dead last with only $5229, on average, per recipient being spent.

Probably because too many people were invited to Thanksgiving…in 2012, Illinois had 2.626 million Medicaid recipients enrolled….or too many rats and ants.

Compare to NC in 2012 – 1.471 million Medicaid recipients.

What was Alaska’s Medicaid budget/spending in 2012 that the average spending per enrollee was $13,073?

$1.425 million spent.  Up 10.3% from 2011.  And 109,000 Medicaid enrollees.

Here is NC:

Spending: $13.872 million. Up 22.8% from 2011. And 1.471 million recipients.

Here is a crazy one..Nevada:

In 2012, Nevada had 301,000 Medicaid enrollees.  A little under 3x Alaska.  Nevada spent $1.692 million on Medicaid (only 200,000-ish over Alaska), but Nevada’s average spending per enrollee was $5,621 (less than half of Alaska and the third lowest amount spent per enrollee).  Where did all Nevada’s Medicaid money go?? Rats and ants eating away the pie?

North Dakota has the very least number of Medicaid enrollees in 2012…66,000.  Wyoming is a close second with only 67,000 Medicaid enrollees in 2012.

North Dakota was the 4th highest state as to spending per enrollee with an average of $10,969/enrollee.

Wyoming was the 16th highest state as to spending per enrollee with an average of $8537/enrollee.

Guess which state had the highest total spending on Medicaid in 2012?

Drum roll…..

California. (Shocker!). California spent $47.726 million on Medicaid, up 4.2% from 2011.  California also had the highest number of enrollees on 2012 with 2.624 million enrollees (over a million more than NC).  California also spent the 5th lowest on average per enrollee, $6,065.

Having a high number of enrollees did not always have a direct correlation with spending the least, on average, per enrollee.  Oregon only had 569,000 Medicaid enrollees in 2012 and spent the 4th lowest amount, on average, per enrollee, $6,007.

New York is the closest state to spending and number of recipients to California, but New York succeeded in a much higher average spending per enrollee than California.

New York spent $39.257 million total on Medicaid (less than $8 million difference from California) in 2012.  New York had 5.004 million enrollees (2.8 million Medicaid enrollees less than California) and spent, on average, $7845/enrollee (absolute, dead-on-middle as compared to all states).

Georgia is, perhaps, the most comparable to North Carolina in terms of number of Medicaid enrollees in 2012.  NC = 1.471 million enrollees in 2012.  GA = 1.529 enrollees in 2012.

NC spent $13.872 million, while Georgia spent $8.497 million in 2012.  So, Georgia had MORE Medicaid enrollees and spent over $5 million less……

Is that good or bad?  Is Georgia more efficient?  Did Georgia spend less in administration costs?

Actually (albeit there may be other factors), Georgia spent significantly less, on average, on each Medicaid enrollee.

Georgia spent 2nd lowest, on average, per Medicaid enrollee.  Only Illinois surpassed Georgia in lowest spending, on average, per enrollee.  Georgia spent, on average, $5,229 per enrollee.

NC spent $9430, on average, per enrollee. (Which, BTW, is more than enough for my “A Modest Proposal”).

That is a huge difference!

One other number jumped out at me when I reviewed Modern Healthcare‘s article, “Medicaid Budgets By State.”  Remember I told you that NC spent $13.872 million on Medicaid in 2012…and that the amount spent was a 22.8% increase from 2011?

22.8% is a high percentage to increase in only one year!

I looked at the increases/decreases of the states.  North Carolina gets the award for the highest percentage growth in spending on Medicaid in the entire nation.  NC was the only state whose percentage “increase of Medicaid spending” percentage from 2011 to 2012 was in the 20s.

NC is #1 in the nation for percentage increase as to total Medicaid spending!!!! (Proud?)

The next state with the highest increase in spending on Medicaid is Mississippi with a 17.4% increase in spending from 2011.  Next in line is Alabama with a 14.7% increase in Medicaid spending.

Guess which states decreased its Medicaid spending the most from 2011 to 2012?

Drum roll…

Oregon (decrease of 23.2% spending) and Illinois (decrease of 15% spending).  Is it coincidental that Illinois spent the absolute least, on average, per Medicaid recipient and that Oregon spent the 4th lowest, on average, per Medicaid recipient?

Regardless the size of the pie, the number of guests, and the number of rats and ants, we need to make sure that the guests (Medicaid recipients) are benefitting most from the pie.

Sometimes a decrease in spending equals a decrease in services to Medicaid recipients…sometimes not…I guess it depends on the number of rats and ants.