Medicaid recoupments actions have skyrocketed in the past year. But, in the upcoming year, a new group of health care providers will be targeted for recoupment actions. According to the February 2013 Medicaid Bulletin, health care providers that serve the Medicaid population with inpatient and outpatient hospital care, long-term care, laboratory services, x-ray services, and specialized outpatient therapy claims.
What is a RAC?
In the most simple terms: A RAC is an entity hired by the State to review Medicaid payments to health care providers and, subsequently, recoup the Medicaid overpayents for the State.
This past year hundreds of health care providers in the mental health fields, personal care services, and outpatient behavioral health services have received Tentative Notices of Overpayment. Some Notices claim repayment amounts in the millions.
Well, now, on to the hospitals…Imagine how large hospital recoupments will be….
The most common statements I hear from health care providers when they are going through Medicaid audits is “I did not know THAT was required,” or “No one told us that we had to do THAT,” or, my personal favorite, “I called DMA and they told me we were doing THAT correctly.”
First, if you call DMA, document the conversation in writing. Get the DMA representative’s name, title, and summarize the phone call in a safe place. Then write a letter to DMA summarizing the information you received.
Write something like this: “Per our phone conversation [DATE], you stated that [insert explanation, i.e., you stated that electronic signatures complied with NC Medicaid policy, if I take the following steps…]”
If you take this precaution, filing a note of the conversation and following-up with a letter, the you ensure that DMA cannot, later, deny the conversation. Remember, with oral conversations, no one remembers the conversation exactly the same.
All health care providers, I venture to guess, at some point, needs to call DMA and ask a question. If so, follow Tip #9. But if you find that you or your employees often have questions, BE PROACTIVE.
Do not wait until the Medicaid audit to say, “I did not know THAT was required.”
How to be proactive? EDUCATE! Yourself and all your employees!
One of two ways:
2. Contact a Medicaid attorney (This is not an advertisement for myself, although I have done this for providers, but, please, research other Medicaid attorneys.) and have the Medicaid attorney come to your main office and give a presentation on Medicaid rules. If you go this route, make sure the Medicaid attorney understands what type of Medicaid services you provide, even better, tell the Medicaid attorney your specific concerns regarding your practice.
The upside about attending DHHS seminars is that the seminars are free. The upside of hiring a Medicaid attorney to come to your office, he or she can physically review some of your practices’ documentation for possible common mistakes.
Regardless, whatever you decide, do not do nothing until you received the Tentative Notice of Overpayment. It’s too late then. Be proactive in education.
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.