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.
ONE HUNDRED PERCENT!
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?
East Carolina Behavioral Health (ECBH), one of North Carolina’s 10 MCOs had to defend itself at a local Mental Health Town Hall Meeting in Greenville, NC.
Amy Brown, who works at Arc of North Carolina, which is a company-advocate for people suffering from mental illness and/or developmental disabilities, finally asked what so many providers and recipients have been asking for months:
WHY ARE SERVICES GETTING DENIED????
For the news video, click here.
“It appears that there is a growing trend of families being denied services,” Brown, who works at the Arc of North Carolina, told the panel.
Brown, like other families who have shared their story with 9 On Your Side, is frustrated with East Carolina Behavioral Health – the organization that manages local providers.
She says the processes ECBH requires to approve services for the mentally ill is long, tedious and ineffective.
“For those families that are willing to fight it out and go through the appeals process, it’s very frustrating, it’s very long,” Brown says.
ECBH, or any MCO, that denies medically necessary services, are denying Medicaid services for the most needy.
But, believe me, this is NOT isolated to ECBH. ECBH serves Beaufort, Bertie, Camden, Chowan, Craven, Currituck, Dare, Gates, Hertford, Hyde, Jones, Martin, Northampton, Pamlico, Pasquotank, Perquimans, Pitt, Tyrrell & Washington counties. But medically necessary services are being denied outside the above-mentioned counties.
Not only are medically necessary services being denied, but quality, competent health care providers are being DENIED Medicaid contracts or the Medicaid contracts are being rescinded.
People, listen, if a health care provider resides in Beaufort county, NC, that health care provider, in order to provide mental health services to the Medicaid population must contract with ECBH in order to provide services. There is no other option. The provider cannot, for example, just contract with a different MCO, to provide mental health services within Beaufort county. ECBH is the only option in Beaufort county for a Medicaid contract in behavioral health. So, if ECBH, arbitrarily decides that it does not want to contract with Provider X, for whatever reason, Provider X cannot provide mental health services to Medicaid recipients within Beaufort county and be reimbursed for services rendered. Period.
And this is happening. Providers, who have been providing mental health services to Medicaid recipients for, sometimes, years and years, and who have, some, hundreds of Medicaid recipients, are being denied a Medicaid contract with ECBH, and other MCOs, are not receiving the reimbursement for services rendered for themselves and their staff, and are being forced to close their doors or no longer accept Medicaid patients.
The MCOs, including ECBH, seem to be pushing mental health care providers away from Medicaid, resulting in Medicaid recipients not receiving desperately-needed mental health services.
And here I thought mental health is such an important topic…
It’s easy to proclaim that you care about providers and recipients and you want Medicaid recipients to receive quality health care, but it’s a whole other thing to actually determine if the WAY the system is IMPLEMENTED is broken. Maybe it’s not the Medicaid system that is broken; maybe it is the implementation of the system.
George Bernard Shaw said, “People who say it cannot be done should not interrupt those who are doing it.”