Blog Archives

Do You Pay Your Billing Agent a Percentage of Claims? You May Be in Violation of Federal law!

The Office of Inspector General (OIG) recently disseminated hundreds of recoupment letters to providers in New York who had percentage-based contracts with billing agents. OIG is seeking recoupment for services spanning a five-year period, plus 9% interest. See example redacted letter from OIG.

oig letter

42 CFR 447.10 prohibits the re-assignment of provider claims and applies only to Medicaid. It is recommended that you pay your billing agent a flat fee or on a time basis.

North Carolina Medical Society also discourages fee splitting. On the NCMS website, the Society warns that “Except in instances permitted by law (N.C. Gen. Stat. § 55B-14(c)), it is the position of the Board that a licensee cannot share revenue on a percentage basis with a non-licensee. To do so is fee splitting and is grounds for disciplinary action.”

Not all States prohibit fee splitting, and if Medicare or Medicaid is not involved, then we look to state law. But if Medicare or Medicaid is involved, then federal law matters. Some States prohibit fee splitting for doctors, chiropractors, and hospitals, while other states do not prohibit fee splitting for massage therapists. So it is important to know your State’s laws.

Lawyers also have fee-splitting prohibitions. To split fees with a nonlawyer constitutes the practice of law without a license (and probably multiple other ethical concerns).

Physicians, group practices and management services organizations should continue to carefully examine their current and proposed arrangements to ensure compliance with the fee-splitting prohibition applicable to your State. If you are unsure, consult an attorney.

OIG may have started these audits in New York, but, as New York State says “Excelsior” – ever upward – we can be sure that OIG will continue across the country.

Knicole Emanuel Speaks Out on WRAL: You Do Not Pee in a Cup at the Dentist!

WRAL Knicole

http://www.wral.com/dentists-left-holding-bills-for-services-to-pregnant-women/15311392/

Or click here.

NCTracks, MPW, and Eligibility: The Three Billy Goats Gruff

The story of The Three Billy Goats Gruff tells a tale of 3 billy goats, one puny, one small, and one HUGE. The first two billy goats (the puny and small) independently try to cross the bridge to a green pasture. They are blocked by a mean troll, who wants to eat the billy goats. Both billy goats tell the troll that a bigger billy-goat is coming that would satisfy the troll’s hunger more than the puny and small goats. The troll waits for the HUGE billy-goat, which easily attacks the troll to his death.

The moral: “Don’t be greedy.”

My moral: “You don’t always have to be HUGE, the puny and small are equally as smart.” – (They didn’t even have to fight).

The majority of Medicaid cards do not have expiration dates. Though we have expiration dates on many of our other cards. For example, my drivers’ license expires January 7, 2018. My VISA expires April 18, 2018.

Most Medicaid cards are annually renewed, as well. Someone who is eligible for Medicaid one year may not be eligible the next.

medicaid card

Our Medicaid cards, generally, have an issuance date, but not an expiration date. The thought is that requiring people to “re-enroll” yearly is sufficient for eligibility status.

Similar to my CostCo card. My Costco card expires annually, and I have to renew it every 12 months. But my CostCo card is not given to me based on my personal circumstances. I pay for the card every year, which means that I can use the card all year, regardless whether I move, get promoted, or decide that I never want to shop at CostCo again.

Medicaid cards, on the other hand, are based on a person’s or family’s personal circumstances.

A lot can happen in a year causing someone to no longer be eligible for Medicaid.

For example, a Medicaid recipient, Susan, could qualify for Medicaid on January 1, 2015, because Susan is a jobless and a single mother going through a divorce. She has a NC Medicaid card issued on January 1, 2015. She presents herself to your office on March 1, 2015. Unbeknownst to you, she obtained a job at a law office in February (Susan is a licensed attorney, but she was staying home with the kids when she was married. Now that she is divorced, she quickly obtained employment for $70,000/year, but does not contact Medicaid. Her firm offers health insurance, but only after she is employed over 60 days. Thus, Susan presents herself to you with her Medicaid card).

If Susan presents to your office on March 1, 2015, with a Medicaid card issued January 1, 2015, how many of you would double-check the patients eligibility in the NCTracks portal?

How many would rely on the existence of the Medicaid card as proof of eligibility?

How many of you would check eligibility in the NCTRacks portal and print screen shot showing eligibility for proof in the future.

The next question is who is liable for Susan receiving Medicaid services in March when she was no longer eligible for Medicaid, but held a Medicaid card and, according to the NCTracks portal, was Medicaid eligible??

  • Susan?
  • You, the provider?
  • DHHS?
  • NCTracks?

Do you really have to be the HUGE billy goat to avoid troll-ish recoupments?

Susan’s example is similar to dental services for pregnant women on Medicaid for Pregnant Women (MPW). MPW expires when the woman gives birth. However, the dentists do not report the birth of the child, the ob/gyn does. Dentists have no knowledge of whether a woman has or has not given birth. See blog.

MPW expires upon the birth of the child, and that due date is not printed on the MPW card.

I daresay that the dentists with whom I have spoken have assured me that every time a pregnant woman presents at the dental or orthodontic offices that an employee ensures that the consumer is eligible for dental services under MPW by checking the NCTracks portal. (Small billy-goat). Some dentists go so far to print out the screenshot on the NCTracks portal demonstrating MPW eligibility (HUGE billy-goat), but such overkill is not required by the DMA Clinical Coverage Policies.

If the clinical policies, rules, and regulations do not require such HUGE billy-goat nonsense, how can providers be held up to the HUGE billy-goat standard? Even the puny billy-goat is, arguably, reasonably compliant with rules, regulations, and policies.

NCTracks is not current; it is not “live time.” Apparently, even if the woman has delivered her baby, the NCTracks portal may still show that the woman is eligible for MPW. Maybe even for months…

Is the eligibility fallacy that is confirmed by NCTracks, the dentists’ fault?

Well, over three (3) years from its go-live date, July 1, 2013, NCTracks may have finally fixed this error.

In the October 2015 Medicaid Bulletin, DHHS published the following:

Attention: Dental Providers

New NCTracks Edits to Limit Dental and Orthodontic Services for Medicaid for Pregnant Women (MPW) Beneficiaries

On Aug. 2, 2015, NCTracks began to deny/recoup payment of dental and orthodontic services for beneficiaries covered under the Medicaid for Pregnant Women (MPW) program if the date of service is after the baby was delivered. This is a longstanding N.C. Medicaid policy that was previously monitored through post-payment review.

According to N.C. Division of Medical Assistance (DMA) clinical coverage policy 4A, Dental Services:

For pregnant Medicaid-eligible beneficiaries covered under the Medicaid for Pregnant Women program class ‘MPW,’ dental services as described in this policy are covered through the day of delivery.

Therefore, claims for dental services rendered after the date of delivery for beneficiaries under MPW eligibility are outside the policy limitation and are subject to denial/recoupment.

According to DMA clinical coverage policy 4B,Orthodontic Services:

Pregnant Medicaid-eligible beneficiaries covered under the Medicaid for Pregnant Women program class ‘MPW’ are not eligible for orthodontic services as described in this policy.

Therefore, claims for orthodontic records (D0150, D0330, D0340, and D0470) or orthodontic banding (D8070 or D8080) rendered for beneficiaries under MPW eligibility are outside of policy limitation and are subject to denial/recoupment.

Periodic orthodontic treatment visits (D8670) and orthodontic retention (D8680) will continue to be reimbursed regardless of the beneficiary’s eligibility status at the time of the visit so long as the beneficiary was eligible on the date of banding.

Seriously? “Now I’m coming to gobble you up!!”

August 2, 2015, is over two years after NCTracks went live.

In essence, what DHHS is saying is that NCTracks was inept at catching whether a female Medicaid recipient gave birth. Either the computer system did not have a way for the ob/gyn to inform NCTracks that the baby was delivered, the ob/gyn did not timely submit such information, or NCTracks simply kept women as being eligible for MPW until, months later, someone caught the mistake. And, because of NCTracks’ folly, the dentists must pay.

How about, if the portal for NCTracks state that someone is eligible for MPW, then providers can actually believe that the portal is correct??? How about a little accountability, DHHS???

If you take MPW and want to avoid potential recoupments, you may need some pregnancy tests in your bathrooms.

DHHS is expecting all dentists to be the HUGE bill goat. Are these unreasonable expectations? I see no law, rules, regulations, or policies that require dentists to be the HUGE billy goat. In fact, the small and puny may also be compliant.

“You don’t always have to be HUGE, the puny and small are equally as smart.”

Federal Audit Spurs NC to Recoup from Dentists Who Accept MPW!!

When providers receive Tentative Notices of Overpayment (TNOs), we appeal the findings. And, for the most part, we are successful. Does our State of NC simply roll over when the federal government audits it??

A recent audit by Health and Human Services (HHS) Office of Inspector General (OIG) finds that:

“We recommend that the State agency:

  • refund $1,038,735 to the Federal Government for unallowable dental services provided to MPW beneficiaries after the day of delivery; and
  • increase postpayment reviews of dental claims, including claims for MPW beneficiaries, to help ensure the proper and efficient payment of claims and ensure compliance with
    Federal and State laws, regulations, and program guidance.”

MPW is Medicaid for Pregnant Women.  Recently, I had noticed that a high number of dentists were receiving TNOs.  See blog.  I hear through the grapevine that a very high number of dentists recently received TNOs claiming that the dentists had rendered dental services to women who had delivered their babies.

Now we know why…

However, my question is: Does NC simply accept the findings of HHS OIG without requesting a reconsideration review and/or appeal?

It seems that if NC appealed the findings, then NC would not be forced to seek recoupments from health care providers.  We already have a shortage of dentists for Medicaid recipients.  See blog and blog.

And if the federal auditors audit in similar fashion to our NC auditors, then the appeal would, most likely, be successful. Or, in the very least, reduce the recouped amount, which would benefit health care providers and taxpayers.

Whenever NC receives a federal audit with an alleged recoupment, NC should fight for NC Medicaid providers and taxpayers!!  Not simply roll over and pay itself back with recoupments!

This audit was published March 2015.  It is September.  I will look into whether there is an appeal on record.

Liability Insurance for Health Care Providers: Is It Adequate?

When you, as a health care provider, undergo a regulatory Medicare or Medicaid audit, your liability insurance could be your best friend or your worst enemy. It is imperative that you understand your liability coverage prior to ever undergoing an audit.

There are two very important issues that you need to know about your liability insurance:

1. Whether your liability insurance covers your choice of attorney; and
2. Whether your liability insurance covers settlements and/or judgments.

I cannot express the importance of these two issues when it comes to regulatory audits, paybacks and recoupments. Let me explain why…

Does your liability insurance cover attorneys’ fees for your choice of provider?

I have blogged numerous times over the past years about the importance of knowing whether your liability insurance covers your attorneys’ fees. I have come to realize that whether your liability insurance covers your attorneys’ fees is less important than knowing whether your liability insurance covers your choice of attorney. Believe it or not, when it comes to litigating regulatory issues in the Medicare/Medicaid, attorneys are not fungible.

A client of mine summed it up for me today. She said, “I wouldn’t go to my dentist for a PAP smear.”

Case in point, here are some examples of misconceptions that attorneys NOT familiar with the Office of Administrative Hearings (OAH) might think:

Myth: Getting the case continued is a breeze, especially if all the parties consent to it.

Reality: Generally, OAH is reluctant to continue cases, except for good cause, especially when a case has pended for a certain amount of time. (This has been a more recent trend and could change in the future).

Myth: When my case is scheduled for trial on X date, it will be a cattle call and we will only determine when the case will be actually heard, so I don’t need to prepare for trial. (This is true in superior court).

Reality: Incorrect. Most likely, you will be heard. OAH has a number of administrative law judges (ALJs) who are assigned cases. Generally, they only schedule one case per day, although there are exceptions.

Myth: Since we are going to trial next week, the other side must not intend to file a motion to dismiss or motion for summary judgment. I don’t need to prepare any counter arguments.

Reality: The administrative rules allow attorneys to orally file motion the day of trial.

You can imagine how devastating attorney misconceptions can be to your case. An attorney with these misconceptions could very well appear unprepared at a trial, which could have catastrophic consequences on you and your company.

Tip:

Review your liability insurance. Determine whether your liability insurance covers attorneys’ fees. Then determine whether it covers your choice of attorney.

Does your liability insurance cover settlements and/or judgments?

Recently, a client was informed that the agency allegedly owes over $400,000 to the auditing agency. We will call him Jim. Jim came to me, and I instructed him to determine whether his liability insurance covers attorneys’ fees. It turned out that his insurance did cover attorneys’ fees, but only a certain attorney. Jim had overlooked our first issue.

Despite the fact that his insurance would not cover my fees, he opted to stick with me. (Thanks, Jim).

Regardless, once settlement discussions arose between us and the auditing entity, which in this particular case was Palmetto, I asked Jim for a copy of his liability insurance. If his liability insurance covers settlements, then we have all the incentive in the world to settle and skip an expensive hearing.

I was shocked at the language of the liability insurance.

According to the contract, insurance company would pay for attorneys’ fees (just not mine). Ok, fine. But the insurance company would contribute nothing to settlements or judgments.

What does that mean?

Insurance company could provide Jim with bargain basement attorneys, the cheapest it could find, with no regard as to whether the attorney were a corporate, litigation, real estate, tax, bankruptcy, or health care lawyer BECAUSE

The insurance company has no skin in the game. In other words, the insurance company could not care less whether the case settles, goes to trial, or disappears. Its only duty is to pay for some lawyer.

Whereas if the insurance company were liable for, say, 20% of a settlement or judgment, wouldn’t the insurance company care whether the hired lawyer were any good?

Tip:

Print off your liability insurance. Read it. Does your liability insurance cover attorneys’ fees for your choice of provider?

Does your liability insurance cover settlements and/or judgments?

Knicole Emanuel Interviewed by ABC: SOME MEDICAID PROVIDERS OWE DHHS BIG BUCKS

pic of my interview

Jon Camp, journalist for ABC11, interviewed me yesterday about a durable medical equipment client.  In case you missed it, here is the link:

http://abc11.com/video/embed/?pid=773639

NCTracks

NC Docs Face Retroactive Medicaid Rate Cut

This is a story from NC Health News by Rose Hoban…a follow up blog to come

In the 2014 state budget passed last August, state lawmakers inserted what could be considered a poison pill for Medicaid providers: a 3 percent pay cut that for specialists could be effective retroactively to January 2014.

Primary care providers such as pediatricians, internists and family doctors will see the same pay cut, effective back to Jan. 1, 2015.

But the cut is only now being implemented.

“All of us were optimistic that the cut wouldn’t happen,” said Karen Smith, a family doctor in Raeford who runs her own practice.

Smith said she and other physicians have been writing, calling and talking to legislators, working to convince them not to implement the cut.

But she and thousands of other primary care providers received notification late last week that on March 1 they would begin seeing the 3 percent cut.

And for specialists, the reduction will go back 14 months.

“It’s quite a hit,” said Elaine Ellis, spokeswoman for the North Carolina Medical Society.

Failed shared-savings plan behind the problem

The origin of the 3 percent cut goes back to the 2013 budget for Medicaid, the program that covers health care for low-income children, some of their parents, pregnant women and low-income seniors. In 2013, the federal government paid North Carolina 65.5 percent of every dollar billed for Medicaid-eligible care, while the state covered the other 34.5 percent (The rate, which changes annually, is 65.9 percent for 2015).
In 2013, the Medicaid budget had grown to close to $4 billion in state dollars, and lawmakers at the General Assembly were looking for ways to trim costs. So they devised a “shared-savings” program, in which Medicaid providers would take a 3 percent rate cut that would be collected by the state Department of Health and Human Services. If doctors and hospitals saved money by operating more efficiently, DHHS would share those savings back with the providers, effectively reducing the amount of the 3 percent cut.

But DHHS needed federal approval to initiate the program, which would have been complicated. The agency never submitted a plan to the federal government, so neither part of the program was initiated.

That created a problem for lawmakers, who had calculated the savings from the rate cut into their state budget. When lawmakers returned to Raleigh in 2014 to adjust the state’s biennial budget, they implemented the rate cut retroactively to Jan 1, 2014 for specialists. Primary care providers, such as Karen Smith, had their rate cut put off until the beginning of 2015.

Big bucks

Officials from the Medical Society have been gathering numbers from around the state and are finding that some specialty practices could owe tens of thousands of dollars that would need to be repaid to state coffers.

The need for retroactive payment is in part a logistical problem: The computerized Medicaid management information system, known as NCTracks, has not been able to process the cuts. NCTracks has had technical issues since it was rolled out in mid-2013; at that time, glitches in the system created months of delays and tens of thousands of dollars in unpaid services for providers.

“Requiring these [specialist] medical practices to pay back 3 percent of what the state has already paid them for the last 14 months would wreak havoc with the finances of these businesses – really, any business would struggle to recover from such a financial blow,” Robert Schaaf, a Raleigh radiologist and president of the Medical Society, wrote Monday in a press release.

And primary care doctors like Smith are also fretting over paying back 3 percent of what she earned from Medicaid for the past two months.

“Practices such as my own are functioning on an operating budget that’s month by month,” said Smith, who said that a great many of her patients are Medicaid recipients.

“We simply do not have that type of operating reserve to allow for that,” she said.

The cuts will be especially tough for rural providers, who have high numbers of Medicaid patients, said Greg Griggs from the N.C. Academy of Family Practitioners (The Academy of Family Practitioners is a North Carolina Health News sponsor).

“It’s one thing to make the cuts going forward, but to take money back, especially for that period of time, is pretty significant for people who’ve been willing to take care of our most needy citizens,” Griggs said.

“It’s pretty bad,” he said, “and its not like Medicaid pays extraordinarily well to begin with.”

Piling on

In addition to the state cut is a federal cut of 1 percent to Medicaid reimbursements for primary care providers that went into effect on Jan. 1.

As part of the Affordable Care Act, primary care providers like Smith got a bump in reimbursement last year, but that ran out with the new year. Smith said that legislators in other states found ways to keep paying that enhanced rate for primary care doctors.

“We were hoping our legislators would do the same,” she said.

Instead, Smith finds herself talking to her staff about possible reductions, and she’s hearing from providers in her area that they’re throwing in the towel.

“I already have colleagues who’ve left practice of medicine in this area,” she said. “My personal physician is no longer in this area. Another colleague who was a resident three years in front of me told me he cannot deal with the economics of practicing like this anymore.”

Smith acknowledged that North Carolina’s Medicaid program has a slightly higher reimbursement to physicians than surrounding states. But she said many of her patients are quite ill.

“We are in the stroke belt,” she said, referring to the high rate of strokes in eastern North Carolina. “When we look at how sick our patients are compared to other states, is it equivalent? Are we measuring apples to apples?

Medicaid Self-Auditing: Avoid the Remedy Worse Than the Disease

Medicaid providers,

One of the best proactive measures to protect yourself from a Medicaid audit (all this goes for all types of providers… hospitals, psychiatrists, dentists…) is to conduct a self-audit. Without question. That way you can identify potential issues and fix them; thereby, in the long run, limiting your liability to a recoupment. But…TAKE HEED!

If you are going to self-audit, then fix any errors found.  Do not find errors and do nothing.  If you neglect to fix the errors found in a self-audit, then the penalty for not fixing a known error COULD be harsher than never knowing the errors.

Remember the fable, “The Hawk, the Kite, and the Pigeons?”

THE PIGEONS, terrified by the appearance of a Kite, called upon the Hawk to defend them. He at once consented. When they had admitted him into the cote, they found that he made more havoc and slew a larger number of them in a single day, than the Kite could possibly pounce upon in a whole year.

Moral:
Avoid a remedy that is worse than the disease.

I am definitely not comparing the Division of Medical Assistance (DMA) to a kite.  Maybe Aesop should have used two, equally, scary animals, but, in Aesop’s defense, I’m sure that the pigeons were terrified of the kite.

As for the pigeons…A Wisconsin-based medical clinic conducted an internal audit of 25 claims per physician. Good job! Be proactive!

However, the clinic discovered that 2 physicians were up-coding over 10% of their claims. As required, the clinic returned overpayments for those specific, up-coded claims.  So, obviously, whoever conducted this self-audit on the Wisconsin clinic informed the 2 physicians that their abhorrent billing practices were discovered and that they should immediate cease all up-coding, right? Or, at the very least, continued to monitor these 2 physicians’ billings, right?

Wrong.

The clinic conducted no more self-audits on those 2 physicians.  In fact, the clinic stopped conducting self-audits all together.  Furthermore, the clinic allowed those 2 physicians to continue billing without supervision. Ugh!

As expected, a former employee filed a whistleblower lawsuit against the clinic.  The lawsuit is pending, so we have no way of knowing the extent of whatever penalty this clinic may suffer. But, the warning is out! If a practice is billing Medicaid incorrectly, discovers the errors, and fails to take corrective action it COULD be considered fraud.

If you want to read the whole article click here.

The moral of the story? Avoid a remedy that is worse than the disease.

Overinclusive NC Medicaid Recoupments and the Provider “Without Fault” Defense

“It is one thing to believe in witches, and quite another to believe in witch-smellers.” G.K. Chesterton

Similarly to the Salem witch trials in Salem, Massachusetts between February 1692 and May 1693, there has become a sort of mass hysteria surrounding Medicaid fraud.  While, obviously, Medicaid fraud needs to be found and fully prosecuted, who is to determine whether document noncompliance is fraud?  Or harmless and inadvertent error?  The witch-smellers? Good gracious, who can honestly tell me that they understand every aspect of Medicaid billing, including all of the federal statutes germane to Medicaid, and all the terms within DMA Polices and what exactly the terms mean? Medicaid is esoteric stuff.  Surely, providers deserve some leniency as to inadvertent errors. 

Fraud is an intentional deception made for personal gain or to damage another individual or entity. How can an inadvertent error constitute fraud? If I accidentally write the wrong date on a legal bill, can my client point out the error and refuse to pay due to document noncompliance? (The answer is NO, people)

Yet it seems as though the North Carolina RACs auditors are of the mindset that any error, however small and insignificant, causes noncompliance and the reimbursement for services rendered must be recouped.  According to the  AHIMA website, the RAC Program’s purpose is to reduce improper Medicare/Medicaid payments and implement actions to prevent future improper payments.  But who defines “improper?” Is there an element of intent? 

I guess I would also be of the mindset that all errors constitute noncompliance if I were paid 12.8% of what I recouped, too. 

So what defenses do providers have? Back in Salem in 1692-1693, the accused witches would plea, “No. I am not a witch.”  Providers are claiming, “No. My documents are compliant.”  But when the accusor has more power than the accused, the accused plea of, “I did not do it,” falls on deaf ears.

I have found a number of defenses for the health care provider.  One such defense is the provider “without fault” defense.  The provider “without fault” defense is just one of many defenses, and all defenses should be used, but here is an explanation of the provider “without fault” defense:

42 U.S.C. 1395pp states, in pertinent part,

Conditions prerequisite to payment for items and services notwithstanding determination of disallowance:
Where:

2) both such individual and such provider of services or such other person, as the case may be, did not know, and could not reasonably have been expected to know, that payment would not be made for such items or services under such part A or part B of this subchapter

then to the extent permitted by this subchapter, payment shall, notwithstanding such determination, be made for such items or services (and for such period of time as the Secretary finds will carry out the objectives of this subchapter), as though section 1395y(a)(1) and section 1395y(a)(9) of this title did not apply and as though the coverage denial described in subsection (g) of this section had not occurred. (emphasis added)

The U.S. Court of Appeals described 42 U.S.C. 1395pp as “the statutory section [that] allows a [health care provider] to obtain a waiver of liability for overpayment receipt when coverage is later denied and the individual beneficiary of the [health care provider] “did not know, and could not reasonably have been expected to know,  that payment would not have been made for such [services]”…” MacKenzie Med. Supply, Inc. v. Leavitt, 506 F.3d 341, (4th Cir. 2007).

The MacKenzie case dealt with a durable medical equipment provider. The case actually did not end well for the DME provider based on the provider relying on Certificates of Medical Necessity as a sole basis for medical necessity. 

There has not been a ton of case law in which the provider asserted this “no fault” defense, so we really do not know the limitations or breadth of the defense.  But, the “no fault” defense should definitely be in the arsenal of defenses for the providers undergoing recoupment actions.  Let’s say, one arrow in the quiver of defenses.

Going back to the original quote:

“It is one thing to believe in witches, and quite another to believe in witch-smellers.” G.K. Chesterton

I am sure that the witch-smellers back in 1692-1693 had a personal investment in finding witches. I mean, who wants to live in the same community with a witch that could possibly put a spell on you?  Similarly the RACs have personal investments in the way of monetary incentives to cite noncompliance.

One way in which the citizens of Salem determined whether someone was a witch was the “Touch Test.”  If the accused witch touched the victim while the victim was having a fit, and the fit then stopped, that meant the accused was the person who had afflicted the victim.  Yet as ridiculous and asinine as the Touch Test sounds, people believed the witch-smellers.  Even lawyers and judges believed the witch-smellers.

But because of the mass hysteria of the witch hunts, the witch-smellers were believed. 

Today’s mass hysteria of Medicaid fraud is allowing the RACs to be overinclusive when determining noncompliance.  The state has asserted that, if there is grey area, the state errs on the side of the provider. 

From what I have seen, I believe that the state errs on the side of the providers as much as I believe in the “Touch Test” to determine witchcraft.

Contracted NC Agencies Recouping Medicaid: Not Following the Law?

One of my biggest complaints about the NC Medicaid auditing procedures is that services that were prior approved by the correct contracted company, now, at a later date, the prior authorization is being questioned by a, sometimes, different company which determines that medical necessity was not met…despite that medical necessary WAS met earlier.

In all my reconsideration reviews, I have made the “it’s not fair” argument for the health care providers to be told medical necessity was met, only to be told later that medical necessity was not met. I mean, can it get any more confusing?  The only answer I received from DMA representatives was that this “look-back audit” is allowed by federal and state law.

I agree that audits are allowed by federal and state law.  I do not agree that overturning past authorization of medical necessity is allowed by federal and state law.

N.C. Gen. Stat 108C-7(c), which regulates prepayment reviews, states, in pertinent part:

“For any claims in which the Department has given prior authorization, prepayment review shall not include review of the medical necessity for the approved services.”

Shall NOT include review of medical necessity.  Shall not.  Yet, in reconsideration reviews, I am, over and over again, arguing with Department representatives that this particular Medicaid recipient met medical necessity.

Shouldn’t someone tell the Department and the recoupment auditing companies that prepayment review shall not include review of the medical necessity?