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Massive Medicaid Metamorphosis: Providers Beware! Be Proactive NOT Reactive!

Medicaid is ever-changing. But every 5 years or so, it seems, that a substantial section of Medicaid is completely revamped. Sometimes to the detriment of many uninformed, un-suspecting providers. For providers, it is imperative to stay above the curve…to foresee the changes in Medicaid, to plan for those changes, and to morph your own practice into one that will persevere despite the changes to come.

We are on the brink of a massive Medicaid metamorphosis.

Medicaid modifications have happened in the past. For example, a substantial shift in Medicaid occurred when DHHS switched from HP Enterprises to Computer Science Corporation (CSC) as its billing vendor. When the NCTracks system went live, the new NCTracks system forced office managers to re-learn how to bill for Medicaid. It was a rough start and many office managers spent countless hours inputting information into NCTracks, only to get erroneous denials and high blood pressure.

Another example of a Medicaid modification was the implementation of the managed care organizations (MCOs) which came on the heels of the new CABHA certification requirements. Only a couple of years after the shellshock of CABHA certification and thousands of providers going out of business because they could not meet the demands of the CABHA standards, behavioral health care providers were again put through the wringer with new standards created and maintained by the MCOs.

Think about it…Ten years ago, we never used the acronym MCO.

Enter [stage left]: A NEW ACRONYM!!

PLE

Don’t you love acronyms? My family has this game called Balderdash. It is one of my favorite games. The object of the game is to have the best fabricated answer. For example, if the category is “Acronym,” the “Dasher” will read the acronym, say, “PLE.” All the players draft their fake renditions of what “PLE” really means.

Plato Learning Environment; or
Panel of Legal Experts; or
Perinatal Lethality.

You get the point. In the game, the players vote on which answers they believe are correct (BTW: All of the above are real definitions for the acronym “PLE” (according to Google).)

In the Medicaid/care world, we play alphabet soup constantly. MCO, DD, SAIOP, DHHS, BWX, MID CPT….Throw out a few letters, and, most likely, you will have said some acronym that means something to someone. See my acronym page for a list of those pertinent to us (and it is ever-growing).

The most recent new acronym to the Medicaid arena here in North Carolina that I have seen is PLE, which is the crux of the new, upcoming massive Medicaid metamorphosis.

House Bill 372’s short title is “Medicaid Modernization” and has passed in the House.

On June 25, 2015, the Senate passed the House Bill on its first read!

I waited to blog about HB 327 until the Senate had an initial reaction to it. If you recall, the Senate and House has been on contradictory sides when it comes to Medicaid reform. However, it appears that HB 327 may have some traction.

House Bill 372 defines PLE as “[a]ny of the following:

a. A provider.
b. An entity with the primary purpose of owning or operating one or more providers.
c. A business entity in which providers hold a controlling ownership interest.”

Over the last couple years, the Senate and the House have stood divided over whether Medicaid should be managed by ACOs (House) or MCOs (Senate). It appears from the definition of a PLE, that a PLE could be a much simpler version of an ACO, which has had my vote since day 1. The whole concept of an ACO is a provider-run entity in which the providers make the decisions instead of utilization reviews, which have little to no contact with the patients, and, sometimes little health care experience, especially on the provider side.

From my cursory review of the proposed PLEs, it seems that a PLE would mimic an ACO, except, and, further federal research is needed, without some of the highly-regulated mandates that the federal government requires for MCOs (it will still be highly-regulated).

Is this just a question of semantics?  Is this just a question of changing its name?

“What’s in a name? that which we call a rose, By any other name would smell as sweet.” Romeo and Juliet, Act II, Scene II.

Let’s look again at the definition of a PLE, according to Version 3 of House Bill 372.

a. A provider.
b. An entity with the primary purpose of owning or operating one or more providers.
c. A business entity in which providers hold a controlling ownership interest.”

A provider?

Any provider? Does that provider need to ask to become a PLE or is it automatic? Does being a PLE give enhanced benefits other than being just a provider?

The answer is that all providers are not PLEs and providers will need to undertake significant legal and administrative steps to become a PLE.

“PLEs shall implement full-risk capitated health plans to manage and coordinate the care for enough program aid categories to cover at least ninety percent (90%) of Medicaid recipients to be phased in over five years from the date this act becomes law.”

What is “full risk?”

“Full risk” is not defined in HB 372, although, I believe that the definition is self-evident.

Capitation payment is defined by reference to 42 CFR 438.2:

“Capitation payment means a payment the State agency makes periodically to a contractor on behalf of each beneficiary enrolled under a contract for the provision of medical services under the State plan. The State agency makes the payment regardless of whether the particular beneficiary receives services during the period covered by the payment.”

Interestingly, this definition for “capitation payment” is found in the same section of the Code of Federal Regulations (CFR) as all the managed care regulations. Part 438 of the CFR applies to managed care.

We have managed care organizations in our state now managing the behavioral health care aspect of Medicaid. Will the same provisions apply to MCOs…to ACOs…to PLEs?

A rose by any other name…

What else does House Bill 372 purport to do?

• Within 12 months, the Department shall request a waiver from CMS to implement the components of this act.
• Within 24 months, the Department will issue an RFP for provider-led entities to bid on contracts required under this act.
• Within 5 years, 90% of all Medicaid services must be provided from a PLE, except those services managed by the MCOs , dental services, pharmaceutical products and dispensing fees. The Department may implement a pilot within 3 years.

As a provider, if you want to continue to serve the Medicaid population, then you may want to insert your company or agency into the creation of the PLEs, whether you sell, merge, acquire, or create a conglomerate.

It is my prediction that those providers who are reactive, instead of proactive, will lose business, consumers, and, potentially, a lot of cash. It is my “predictive recommendation” [as you are aware, we do not have an attorney/client relationship, so no recommendation of mine is tailored for you] that those providers who proactively seek mergers, acquisitions, and/or business agreements with other providers to morph into PLEs will be more successful, both financially and in serving their consumers better.

What you need to know about the future PLEs:

  • Must cover at least 30,000 recipients
  • Must provide all health benefits and administrative services, including physical, long-term services and supports, and other medical services generally considered physical care
  • Must meet solvency requirements
  • Must provide for appeal processes
  • Will cover 100% of the NC counties

The PLEs will, effectively, absorb the Medicaid dollars for recipients across the entire state and provide care for all physical health needs of Medicaid recipients.

In this environment, providers need to be proactive, not reactive!

If House Bill 327 passes into law, our next Medicaid metamorphosis will be monumental!  And the state will issue an RFP for providers within 2 years!

Lawmakers Demand Accountability as to NCTracks Debacle (Finally) and the Action of Nonaction

Yesterday (11/20/13), State Auditor Beth Wood appeared before the Joint Program Evaluation Oversight Committee meeting.  Lawmakers and Wood criticized NCTracks, its rollout, and the lack of accountability on the part of the administration. Sen. Stan Bingham, R-Davidson, even asked whether criminal charges could be filed against whomever was in charge of the NCTracks rollout. 

Criminal charges!!

There is little disagreement that the rollout of NCTracks has been a complete CATASTROPHE.  NCTracks went live July 1, 2013, and the past 143 days have been nothing short of a hair-pulling-out, feet-stomping, spit-wielding debacle for most providers. So lawmakers, as the health care providers have been asking for the past 143 days, ask, “Who is to blame?”

Who is to blame?

  • The Department of Health and Human Services (DHHS)?
  • Computer Sciences Corporation (CSC) (the company who designed NCTracks)?
  • Independent Verification and Validation (IV&V) Contractor? (the third-party contractor hired for independent verification and validation of NCTracks)?
  • Governor Pat McCrory?
  • Secretary Aldona Wos?

No one in the administration is stepping up to accept accountability.  The vendors are not accepting responsibility.  It is as if the Department of Health and Human Services (DHHS) is just standing there…watching the debacle…doing nothing.  I am reminded of Dr. T.J. Eckleburg.  Anyone remember who Dr. Eckleburg is?

Dr. T.J. Eckleburg’s spectacled eyes are a powerful symbol in The Great Gatsby, one of my favorite novels of all time, written by F. Scott Fitzgerald.

Dr TJ Eckleburg

Originally, the billboard was erected to promote Dr. Eckleburg’s optometry practice.  The eyes are supposed to symbolize commercialism and the greed of America, but the billboard is neglected and the eyes remain throughout the story to symbolize God watching over Nick Carraway and the other characters.  The eyes seem to be an all-knowing and all-powerful figure over the characters. The eyes frown down on the characters and judge their actions.

Wilson equates T.J.’s eyes to the eyes of God. He recounts to Michaelis what he says to Myrtle after discovering his affair, “‘and I said “God knows what you’ve been doing, everything you’ve been doing. You may fool me, but you can’t fool God!”” However, Michaelis tries to point out to him that “It’s just a billboard.”

Maybe it is not just a billboard. 

Throughout The Great Gatsby, Eckleburg’s eyes watch.  Yet, in the novel, God, symbolized by Dr. T.J. Eckleburg’s spectacles, seems to have abandoned America, leaving only Dr. T.J. Eckleburg behind to stare down with his empty eyes.  Dr. T.J. Eckleburg never moves…never speaks. Yet, Fitzgerald creates this looming, unmoving billboard and characterizes the billboard as God.  And who is more in charge than God?

Similarly, (not as to God, but as to Dr. T.J. Eckleburg), DHHS is supposed to be the all-knowing and all-powerful head of North Carolina Medicaid. 

42 C.F.R. 1396a(5) requires the State Plan to “either provide for the establishment or designation of a single State agency to administer or to supervise the administration of the plan; or provide for the establishment or designation of a single State agency to administer or to supervise the administration of the plan.”

That single state entity is DHHS.

DHHS is charged with watching over all things Medicaid.  DHHS is our Medicaid Dr. T.J. Eckleburg.

When State Auditor Wood was asked by legislators who is to blame, she answered, “The agency.” As in, DHHS.  “Accountability comes at the secretary level, those that report to the secretary, and the governor.”

If DHHS is in charge and Secretary Wos is in charge of DHHS, then (going back to Logic 101) Wos is to blame for the NCTracks debacle.  Right? 

Before jumping up and down and blaming Secretary Wos for NCTracks, remember that it was the prior administration that began the whole NCTracks idea in the first place.  Wos did not come to NC and say, “Hey, let’s change the Medicaid billing system.  There is this company CSC that will be so perfect for the job.  Let’s pay them a ton of money to revamp the entire system.”  No, Wos came to NC with NCTracks already begun.  The past administration started this little ball rolling.  Wos stepped in when the ball was huge and its inertia kept it going…or should we say Wos did not stop the rolling ball.

Does that exonerate Sec. Wos from any accountability and/or blame for the current state of mess Medicaid is now in due to NCTracks? Absolutely not.  It is without question that Sec. Wos is charged with managing DHHS.  It is without question that Sec. Wos has not accepted the accountability of the NCTracks debacle.  Shoot, she hasn’t even admitted there is a problem!! Isn’t admitting there is a problem the first step?

Someone at DHHS made a fatal flaw in implementing NCTracks.  Someone told HP Enterprises to take a hike without ensuring that NCTracks would work.  That is like walking a tight rope with no net!  And that fatal decision is on this administration.

Like Dr. T.J. Eckleburg, DHHS is watching over Medicaid.  And like Dr. T.J. Eckleburg, DHHS is unmoving and silent.

DHHS cannot be a billboard.  Nonaction is not an option.

Senator Bingham asked whether we could fire anybody (whomever was in cgarge of the debacle).  To which, Wood stated, in her normal, no-nonsense manner, “I don’t have a problem firing anybody.”

One News and Observor editorial wrote, “What Wos should have told lawmakers wasn’t that she’s pressing DHHS staff and its computer vendor to pay people who are owed. She should have said, “We thought we were being frugal and instead we were reckless and it has cost everyone a great deal. I take responsibility. I apologize. And I’m determined to keep learning from my mistakes to fulfill the mission of my department.”  Instead, she told the committee, “I assure you that where necessary, I will hold people accountable.”  Excepting herself, of course.”

Right now DHHS is just a billboard.

In fact, maybe the most important nonactions to note are what Sec. Wos is NOT doing.  She has has NOT blamed CSC.  She has NOT condemned CSC.  She has NOT had heads rolling at CSC.   Sec. Wos has NOT publicly spoken disparagingly about CSC’s implementation of NCTracks.  She has NOT terminated CSC’s contract.  To my knowledge, she has NOT asked for help from HP Enterprises.  Right now, DHHS is nothing more than a billboard, a symbol of Medicaid, but doing nothing.

In fact, on Tuesday, DHHS representatives tried to tell the Joint Program Evaluation Oversight Committee that NCTracks was improving and its “trajectory is good.”  Doing nothing…just watching…

In The Great Gatsby, Dr. T.J. Eckleburg’s eyes never change.  They continue to watch.  Unlike Dr. T.J. Eckleburg, Sec. Wos can move.  She needs to move. 

Yet, whereas Wood said that she doesn’t have a problem firing anybody, Wos stated on Tuesday “that, where necessary, I will hold people accountable.” 

Where necessary?? 

Aren’t we to “where necessary” yet?  143 days after the catastrophic implementation of NCTracks and the mess is not fixed….don’t you think it is necessary to hold someone accountable??

Oh, and by the way, during these past 143 days since NCTracks’ implementation, who is getting harmed?  The doctors, the dentists, the in-home health care providers who are not receiving proper Medicaid reimbursements.  And then who suffers? The Medicaid recipients because providers stop accepting Medicaid.  In a Medicaid system that already discourages providers from accepting Medicaid, NCTracks is certainly not helping.  Counting business damages, loss of clinical time, and unpaid claims, can you imagine the invoice that the harmed providers should serve on DHHS??   Maybe the invoice sent to DHHS should give DHHS 15 days to request a reconsideration review.

One thing is for certain, DHHS (whether or not through Wos) must stop merely being a symbol of Medicaid, a billboard, and start acting… and be accountable.

Because after 143 days of this hair-pulling-out, feet-stomping, spit-wielding debacle for most providers, there aren’t many more hairs, stomps, or spit.