The NC State Auditor Beth Wood released an audit report on Cardinal Innovations yesterday, May 17, 2017. Here are the key findings. For the full report click here.
Cardinal is a Local Management Entity/Managed Care Organization (LME/MCO) created by North Carolina General Statute 122C. Cardinal is responsible for managing, coordinating, facilitating and monitoring the provision of mental health, developmental disabilities, and substance abuse services in 20 counties across North Carolina. Cardinal is the largest of the state’s seven LME/MCOs, serving more than 850,000 members. Cardinal has contracted with DHHS to operate the managed behavioral healthcare services under the Medicaid waiver through a network of licensed practitioners and provider agencies.
• Cardinal spent money exploring strategic opportunities outside of its core mission
• $1.2 million in CEO salaries paid without proper authorization
• Cardinal’s unreasonable spending could erode public trust
• Cardinal should consult and collaborate with members of the General Assembly before taking any actions outside of its statutory boundaries
• The Office of State Human Resources should immediately begin reviewing and approving Cardinal CEO salary adjustments
• The Department of Health and Human Services should determine whether any Cardinal CEO salary expenditures should be disallowed and request reimbursement as appropriate
• Cardinal should implement procedures consistent with other LME/MCOs, state laws, and federal reimbursement policy to ensure its spending is appropriate for a local government entity
My favorite? Recoup CEO salaries. Maybe we should extrapolate.
Ok, so it took me a couple of days to free up some time to discuss the most recent Performance Audit by our State Auditor. This time of year is CRAZY! We had to get our daughter ready for the 4th grade, which entails buying an absurd amount of school supplies. Thank goodness we don’t have to do “back to school” clothes shopping, because she wears uniforms. Yesterday was her first day of school and, apparently, everything went well.
Now, I want to discuss the recent Performance Audit published by Beth Wood, our NC State Auditor, regarding provider eligibility. Prior to going any further, let me voice my opinion that Beth Wood as our State Auditor rocks. She is smart, courageous, and a force of nature. Any comment that may be negative in nature as to the most recent audit is NOT negative as to the audit itself, but to the possible consequences of such an audit. In other words, I do not believe that the Performance Audit as to Medicaid Provider Eligibility is incorrect; I am only concerned as to the possible consequences of such an audit on the Department of Health and Human Services (DHHS) and health care providers.
The Medicaid Provider Eligibility Performance Audit found that “deficiencies in the enrollment process increase the risk of unqualified providers participating in the Medicaid Program.”
And DHHS’ “enrollment review procedures do not provide reasonable assurance that only qualified providers are approved to participate in the NC Medicaid program.”
And “quality assurance reviews were not conducted or were ineffective.”
Basically, the Performance Audit (in layman’s terms) says that DHHS, again, has little to no oversight, lacks supervision over providers, has program deficiencies, and lacks the ability to manage Medicaid provider eligibility requirements adequately. Considering that DHHS is the single agency charged with managing Medicaid in North Carolina, the Performance Audit is yet another blow to the ability of DHHS to do its job.
Gov. McCrory appointed Sec. Aldona Wos as the head of DHHS, effective January 5, 2013. With Sec. Wos at its helm, DHHS has been riddled by the media with stories of management difficulties, high-level resignations, and mismanaged tax dollars. With the amount of media attention shining on DHHS, it is amazing that Sec. Wos has only been there almost a year and a half. Oh, how time flies.
While, again, I do not discount the accuracy of the Medicaid Provider Eligibility Performance Audit, I am fearful that it will spur DHHS to almost another “Salem witch hunt” extravaganza by pushing the already far-swung pendulum of attacks on providers, in the direction of more attacks. DHHS, through its contractors, agents and vendors, has increased its regulatory audits and heightened its standards to be compliant as a provider for a number of reasons:
1. The U. S. Supreme Court’s Olmstead case;
2. The DOJ settlement as to ACTT providers;
3. More oversight by CMS;
4. The ACA’s push for recovery audit contractors (RACs);
5. General need to decrease the Medicaid budget;
6. Increased fraud, waste, and abuse detection standards in the ACA;
7. Monetary incentives on managed care organizations (MCOs) to decrease the number of providers;
Imagine a pendulum swinging…or, better yet, imagine a child swinging on a swing. Before the child reaches the highest point of the swing, an adult runs behind the child and pushes the child even higher, in order to get a little more “umphf” on the swing. And the child goes even higher and squeals even more in excitement. But that’s not always a great idea. Sometimes the child goes flying off.
I am afraid that the Performance Audit will be that adult pushing the child on the swing. The extra little push…the extra little “umphf” to make the pendulum swing even higher.
As with any Performance Audit, DHHS is allowed to respond to Ms. Wood’s findings. One response is as follows:
“In September 2013, DMA established and implemented Management Monitoring Quality Controls (Monitoring Plan) for reviewing approval and denial decisions related to provider applications referred to it by the Contractor due to a potential concern. The Monitoring Plan established standardized policies and procedures and ensures that staff adheres to them in making enrollment determinations.”
In other words, recently DHHS has put forth a more aggressive oversight program as to health care providers and it will only get more aggressive.
In the last year or so, we have seen more aggressive oversight measures on health care provider that accept Medicaid. More audits, more desk reviews, more fraud investigation…and most (that I have seen) are overzealous and incorrect.
Believe me, I would be fine with increased oversight on health care providers, if the increased oversight was conducted correctly and in compliance with federal and state rules and regulations. But the audits and oversight to which I have been privy are over-bearing on providers, incorrect in the findings, and lacking much of due process for, much less respect to the providers.
I am concerned that the extra little “umphf” by this Performance Audit will impact health care providers’ decisions to accept or not to accept Medicaid patients. See my past blogs on the shortage of health care providers accepting Medicaid. “Shortage of Dentists Who Accept Medicaid: The Shortage Continues.” “Provider Shortage for Medicaid Recipients.” And “Prisons and Emergency Rooms: Our New Medicaid Mental Health Care Providers.”
Instead of increasing overzealous audits on health care providers, maybe we should require DHHS, through its contractors, agents, and vendors, to conduct compliant, considerate, and constitutionally-correct audits and oversight. Maybe the “umphf” should be applied more toward DHHS.
A new audit by the State Auditor shows ANOTHER problem at DHHS. This comes on the heels of another audit earlier this month finding that NCTracks is problematic.
Here is the link: State Audit
More commentary to come this evening when I have time to write about the tomfoolery occurring at DHHS
“If we do not learn from history, we are doomed to repeat it.” George Santayana.
In William Shakespeare’s “Julius Caesar,” Caesar is warned to “Beware the Ides of March.” See Act 1, Scene 2. The “ides” of March is the fifteenth. Back when Caesar established the Julian calendar, he also instituted the “ides” of a month. Months have different “ides.” The ides of January, for example, is the thirteenth; the ides of March, May, July and October is the fifteenth.Caesar:
Who is it in the press that calls on me?
I hear a tongue shriller than all the music
Cry “Caesar!” Speak, Caesar is turn’d to hear. Soothsayer:
Beware the ides of March. Caesar:
What man is that? Brutus:
A soothsayer bids you beware the ides of March
Not really sure what the point of the “ides” was, but, regardless, in 44 B.C., March 15th was the “ides” of March.
When Caesar was warned to “Beware the Ides of March,” Caesar would have known that the soothsayer was warning him about March 15th…a date certain.
Similarly, the Department of Health and Human Services (DHHS) was warned that NCTracks was not ready for its July 1, 2013, “go live”date. Who was the soothsayer? The Office of State Auditor…Beth Wood.
In May 2013, prior to NCTracks going live, State Auditor Beth Wood published a Performance Audit that found hundreds of untested issues. The audit warned DHHS that NCTracks was not ready to go live. The May 2013 Performance Audit may as well have said, “DHHS, beware the first of July!”
Late in the day on March 15, 44 B.C., Caesar walked to the Theatre of Pompey, where he would be assassinated by more than 60 conspirators led by Brutus, his close ally…”Et tu, Brutus?” (Meaning…how could you, my closest friend, conspire against me?)
On his way to the theatre, Caesar sees the same soothsayer who had warned him of the ides of March. Caesar joked, “The ides of March have come,” meaning to say that the prophecy had not been fulfilled, to which the seer replied “Aye, Caesar; but not gone.” See Plutarch’s “Parallel Lives.”
I can only imagine the chill that ran down Caesar’s back when the soothsayer warned that the day was not over yet.
Yet, Caesar still walked to the theatre…despite the warning….
Despite the warnings in the May 2013, Performance Audit, DHHS still went live on July 1, 2013.
Since going live, NCTracks has run into a large number of system defects. Providers in NC have been in uproar. From not getting paid, to getting paid the wrong amount, to Medicaid/Medicare crossover issues, to taxonomy issues…the failures and defects of NCTracks have been felt by all Medicaid providers, despite the speciality.
About a month ago, NC General Assembly began demanding answers of DHHS and Computer Sciences Corporation (CSC), the entity that created NCTracks based on a $484 million contract. On October 8, 2013, DHHS and CSC appeared before the Joint Legislative Oversight Committees on Health and Human Services and Information Technology to answer questions about NCTracks issues.
Remember, Sec. Aldona Wos stated, during the committee meeting, that DHHS was not warned by an entity of the risk to go live with NCTracks. To which, Auditor Wood stated, “For the secretary to say there was no independent or anybody else that had given them a look at their risk readiness for going live on July 1 was not a true statement to the committee, and we felt like that the committee needed to know that information.”
State Auditor Wood is the soothsayer. “Beware the first of July!”
Just as the soothsayer did for Caesar, prior to NCTracks going live, Wood warned DHHS that NCTracks was not ready. Just like Caesar, DHHS did not stop NCTracks from going live (he went to the theatre anyway). Just like Caesar’s death, the failure and ineptness of NCTracks was forewarned and could have been prevented. Both DHHS and Caesar ignored the warnings.
So how bad is NCTracks?
According to the December 2013 Performance Audit, “the NCTracks system has encountered more than 3,200 defects.”
Here are the Audit’s findings:
FINDING #1: THE DEPARTMENT HAS AN INADEQUATE FRAMEWORK FOR THE TIMELY RESOLUTION OF NCTRACKS DEFECTS
Since going live, the NCTracks system has encountered more than 3,200 defects. More than 600 defects remain unresolved at the time of the audit.
FINDING #2: THE DEPARTMENT LACKS A COMPREHENSIVE MASTER ACTION PLAN TO ADDRESS NCTRACKS ISSUES
The Department does not have a comprehensive and cohesive master action plan to direct the remediation of technical and operational NCTracks issues.
FINDING #3: NCTRACKS GOVERNANCE CHANGES PRESENT BUDGETARY AND SYSTEM CAPABILITY RISKS TO THE STATE
Since July 1, 2013, there have been major updates to the approach the Department will take to implement required capabilities. These changes present budgetary and system functionality risks to the State.
FINDING #4: STATE GOVERNMENT’S ‘REVOLVING DOOR’ CREATES A PERCEPTION OF BIAS OR CONFLICT OF INTEREST
A former DHHS employee who served for more than four years as the NCTracks Senior Program Manager and Associate Program Director now works for the NCTracks vendor, CSC, as the NCTracks Executive Account Director.
From Finding #4, it appears that CSC, like Brutus, is working hand in hand with DHHS.
If we do not learn from history, we are doomed to repeat it. “Beware the ides of March!”
“Et tu, Brutus?”
Today State Auditor Beth Wood published the December 2013 “NCTracks Post-Implementation Performance Audit.” One of the key findings is that, since NCTracks went live, the NCTracks system has encountered more than 3,200 defects.
This is the second audit that Wood has conducted on NCTracks. The first audit was May 22, 2013, and expressly warned the Department of Health and Human Services (DHHS) that NCTracks was not ready to go live.
More to come in another blog…
NC State Auditor, Beth Wood, Calls Out Inaccuracies Stated at the NC Oversight Committee Regarding NCTracks
After the October 8, 2013, Oversight Committee meeting regarding NCTracks, our State Auditor, Beth Wood, had some clarifying remarks. By clarifying, I mean, Wood points out the (we don’t want to use such a harsh words as “lies”) inadvertent mistruths that came to light at the October 8, 2013, Oversight Committee meeting. (Click the blue phrase to see a portion of the video of the actual meeting).
One inadvertent mistruth was as follows:
During the Oversight Committee, Senator Parmon asked Secretary Wos whether any professional opinion had been given to the Department of Health and Human Service (DHHS) warning DHHS that NCTracks was not ready to go live July 1, 2013.
Secretary Wos answered: “No, Senator.”
Was the State Auditor’s May 2013 Performance Audit explicitly stating that NCTracks was not ready to go live not enough???? Or maybe Secretary Wos did not consider the Performance Audit a “professional opinion.” She may have a point. Perhaps the Performance Audit should be considered “professional fact.”
It is important to remember that this $484 million contract (which price tag has been surpassed) is funded by our tax dollars.
Here is Beth Wood’s response to the Oversight Committee:
October 10, 2013Honorable Justin Burr
NC House of Representatives 300 N. Salisbury Street, Room 307A Raleigh, NC 27603-5925
Dear Representative Burr,
The Office of the State Auditor has several concerns about incomplete information provided to the Joint Legislative Oversight Committee on Health and Human Services during its committee meeting on October 8, 2013. We would like to clarify some of the information provided to the committee by officials from the Department of Health and Human Services.
1. When Senator Parmon asked Secretary Wos whether the Department of Health and Human Services had received any professional opinions indicating that that the NC Tracks system may not be ready to go-live on July 1, the Secretary responded “No, Senator.” This answer ignores the work of our audit issued on May 22, 2013, titled: “NCTracks (MMIS Replacement) – Implementation.” The State Auditor met and presented Secretary Wos with the findings and recommendations as early as March 27, 2013, to allow her department to begin addressing problems uncovered in the audit.
The audit findings from our report included that:
- Independent assessments regarding system readiness and testing were flawed and put system readiness at risk
- Access control and security environment were at risk on go-live
- No formal criteria framework existed to determine if NCTracks was ready for go-live
“The Department should re-evaluate its current “Go” decision for July 1, 2013, once final Go/No-go criteria is established and documented,” our audit recommended. “This assessment should incorporate the final user acceptance testing and production simulation testing results.”
2. In his presentation, Mr. Cooper referenced NCTracks testing procedures done by DHHS and its vendor, CSC, prior to the July 1 go-live date and indicated that the system had met their benchmarks. Our audit, however, found several shortcomings in the testing of the system.
Our findings indicated that:
- Out of 834 “critical” priority test cases affecting various Medicaid and provider business processes, 123 critical tests had failed and 285 critical test cases were not performed. The department itself defined which business processes were critical, and according to the department, “critical” test cases were absolutely required to be tested.
- Our audit stated, “If user acceptance testing is accepted without addressing these issues, a high risk exists that critical NCTracks functions could have major errors on go-live and possibly lead to a delayed CMS certification of the system.”
- Oversight over the production simulation testing process was inadequate. Our work found that the department allowed CSC to develop the acceptance criteria for its own work, one week prior to the end of the testing phase, and that the department lacked clear test benchmarks.
3. Mr. Cooper stated during this presentation that, “On February 28th we [DHHS] reached a point-of-no-return when the state had to cancel the HP contract.” This contradicts what Department leaders told state auditors during our NCTracks pre-implementation audit. During our audit, DHHS senior leadership repeatedly indicated that the termination of the contract with HP, the vendor for the Medicaid system that was replaced by NCTracks, should not be considered final acceptance of the project.
“According to the Department, the letter to HP does not constitute formal acceptance of the NCTracks system,” our audit states. “The Department has indicated that if the NCTracks system is not ready for go-live on July 1, 2013, HP will be willing to continue its services as long as needed. However, there is no guarantee that this continuation of services would occur or at what cost to the State as this is not in writing.”
The fact that Mr. Cooper and the Department now characterize the contract termination as a “point-of-no-return” indicates that the Department’s decision to go-live did not take into account the actual readiness of the system or the critical risks that were raised between February 28 and June 30.
Our full audit report on NCTracks can be viewed at http://www.ncauditor.net/EPSWeb/Reports/InfoSystems/ISA-2013-4410.pdf.
Our staff is available to answer any questions or concerns you may have about our work. If you wish to discuss this information with me, you can contact me at 919-807-7628.
Thank you for your work on behalf of the people of North Carolina.
Sincerely,Beth A. Wood, CPA North Carolina State Auditor