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Williams Mullen Hosts Its First Annual Healthcare Panel Discussion: Summary Below

I am currently sitting in a hotel in New Mexico.  I testified this morning before the New Mexico Behavioral Health Care Subcommittee regarding due process for health care providers upon “credible allegations of fraud.”

This past Sunday I ran and finished my very first half marathon.  And, yes, I am sore.  I signed up for the Bull City 1/2 marathon in Durham because it was being held in October and I thought the temperature would be cool.  But I failed to contemplate Durham’s hills…ouch!

Despite my jet lag and sore muscles, I wanted to blog about the health care panel discussion this past Thursday night hosted by Williams Mullen. Representative Nelson Dollar, Barbara Morales Burke, Blue Cross Blue Shield of NC, Stephen Keene, General Counsel for the NC Medical Society, and I presented as the healthcare panel.  As you can see below, we sat in the above-referenced order.

Panel4

with moderator

Below, I have outlined the questions presented and my personal recollection of each answer.  These answers were not recorded, so, if, by chance, I misquote someone, it is my own personal recollection’s fault, and I apologize.

Our Williams Mullen associate Robert Shaw, acted as the moderator and asked the following questions:

To Rep. Dollar:

Most of us have heard about the discussion in the General Assembly about moving North Carolina’s Medicaid program towards a more fully implemented managed care model or to one using accountable care organizations. Where do the House and Senate currently stand with respect to these models, and what are the prospects for passing Medicaid reform in next year’s long session of the General Assembly?

Summary: The House and the Senate are not in agreement.  The House put forth a Bill 1181 last session that encompasses the House’s ideas for Medicaid reform.  It was a bipartisan bill.  It was passed unanimously.  Medicaid reform should not be a bipartisan matter.  Our Bill did not fare well in the Senate, but the House believes Bill 1181 is the best we have so far.

To which Keene interjected: It is important that Bill 1181 was unanimous. The Medical Society endorses the bill. 

To Barbara Morales Burke:

As we head into open enrollment season under the Affordable Care Act, what are the biggest challenges you see from the insurer’s perspective in complying with Affordable Care Act requirements and meeting the needs of the marketplace?

Summary: BCBS, as all other insurance companies, faced unique times last year during the open enrollment and this year will be even more important because we will find out who will re-new the policies.  While BCBS was not perfect during last year’s open enrollment, we have learned from the mistakes and are ready for the upcoming enrollment.

To Steve Keene:

What concerns are you seeing from members of the North Carolina Medical Society regarding patients’ access to providers of their choice and your members’ participation in the major health insurance networks?

Summary: This has always an issue since he came to NC. He actually wrote a memo regarding the access to provider issue back in the 1990s.  The insurance need to come up with a known a published standard. BCBS actually has better relationships with providers than, say, for example, a United Healthcare.  If the insurance company decides to only use X number of ob/gyns, then it should be clear why the insurance company is only contracting with x number ob/gyns.

To Knicole Emanuel:

Under the Affordable Care Act, the standard for withholding payments in the event of a credible allegation of fraud has changed. What is the standard for a credible allegation of fraud and how does such an allegation affect Medicaid reimbursements?

Summary: The ACA was intended to be self-funding.  In drafting the ACA, 42 CFR 455.23 was amended from allowing states to choose whether to suspend Medicaid reimbursements upon credible allegations of fraud to mandating the states to suspend payments.  The basis for a suspension is credible allegations of fraud and only requires an indicia of reliability.  This indicia of reliability is an extremely low standard and, thus, adversely impacts health care providers who are accused of fraud without a basis, such as a disgruntled employee or anonymous and unfounded complaint.  

For more information on suspension of Medicaid payments, please see my blogs: “How the ACA Has Redefined the Threshold for “Credible Allegations of Fraud” and Does It Violate Due Process?” or “NC Medicaid Providers: “Credible Allegations of Fraud?” YOU ARE GUILTY UNTIL PROVEN INNOCENT!

To Keene and Burke: (ACA topic)

One of the concerns, or perhaps benefits depending on one’s perspective, about the implementation of the Affordable Care Act is the possible transition from our country’s employer-based health insurance model. Are you seeing any trends away from the employer-based health insurance model, or do you expect such a trend in the future?

Summary: (From Keene) He sees the employer-based health insurance model as a tax issue.  Employer-based health insurance is not going anywhere unless the related tax break is eliminated.  Keene does not have an opinion as to whether the employer-based health insurance model is good or bad; he just believes that it is not going anywhere.  On a side note, Keene mentioned that, with employer-based health insurance, the employee has a much smaller voice when it comes to negotiating any terms of the health insurance.  The employee is basically at the whim of the employer and health insurance company.

Dollar and Emanuel: (Medicaid reform)

Who are the major contributors to the legislative discussion on Medicaid funding and reimbursement rates? What stakeholders do legislators want or need to hear from more to make sound policy decisions about funding decisions?

Summary: (From Dollar) It is without question that the legislators are surrounded by lobbyists regarding the discussion as to Medicaid funding and reimbursement rates.  I stated that the reimbursement rates are too low and are a direct correlation as to quality of care.  Rep. Dollar stated that he is open to hearing from all.  Furthermore, Rep. Dollar believes that the Senate Bill on Medicaid reform is a good start for Medicaid reform. The Bill implements the Accountable Care Organizations (ACOs), and is supported by the NC Medical Society.

Summary: (From me) I support Medicaid reform that eliminates the MCOs in behavioral health care.  These MCOs are prepaid and have all the financial incentive to deny services and terminate providers.

Burke: (ACO)

How is Blue Cross Blue Shield of North Carolina working with providers to take advantage of the new Medicare Shared Savings Program? (E.g., partnership signed with WakeMed Key Community Care (an accountable care organization) in July.)

Summary: BCBS works very hard to maintain solid relationships with providers.  To which Keene agreed and stated that other private insurance does not.

The health care panel was great.  We hope to host a State of the State on Health Care panel discussion annually.

Haven’t Fixed Medicaid Yet…But I Haven’t Gotten Bucked Off Yet

There are a number of federal regulations that, if I were in charge, would be immediately amended. Obviously, I am not in charge, so despite my best blogging efforts, my blogs do not change federal law. Today, however, I had the honor and privilege to speak to someone who may have the clout and political pull to fix some of the calamities found in the Code of Federal Regulations (CFRs) that are so detrimental to health care providers who accept Medicare and Medicaid across the country.

My husband, daughter, and I ride horses nearly every weekend. We ride Western and on trails all over North Carolina and Virginia, mostly on charity rides. And over the past few years, I have, sadly, gone through over 5 horses. Not because the horses have passed. But because each horse had an oddity or behavior issue that either (a) I didn’t want to deal with; or (2) terrified me.

For example, Twist of Luck (Twist) is a gorgeous pure, white horse with a yellow tail and mane and brilliant, blue eyes. But he was what you call, “proud cut.” Meaning that because he sired so many foals, even after he became a gelding he thought like a stallion. One weekend we were at Uwharrie National Park and when I saddled up Twist and mounted him, he decided that he did not want me on his back. My husband said Twist looked like a “poster horse” for a rodeo with his back completely rounded like an angry cat and all four of his hooves in the air. Needless to say, I found myself quite quickly on the ground with a sore tooshie, and Twist found himself sold.

Since I do not have the time to actually train my horse, I need a trained horse.

With my hobby of horseback riding, a well-trained horse is imperative…not only for safety, but for my enjoyment as well.

In the area of Medicare and Medicaid, it is imperative for enough physicians, dentists, and other health care providers to accept Medicare and Medicaid. You see, health care providers choose to accept Medicare and Medicaid. And not all health care providers agree to accept Medicare or Medicaid. But it is important for enough health care providers to accept Medicare and Medicaid patients otherwise the Medicare or Medicaid card in a person’s hand is worthless. Same as Twist was worthless to me that day in Uwharrie. If you can’t ride a horse, what is the point of owning it? If you can’t find a health care provider, what is the use of having coverage?

Here in North Carolina, we decided to not expand Medicaid. This blog is not going to address the ever-growing discontent in the media as to the decision, although you can see my blog: “Medicaid Expansion: Bad for the Poor.”

Instead, this blog will address my idea that I pitched to Congresswoman Renee Ellmers over lunch last week and discussed today with her legislative counsel today as to how it can be implemented.

Here’s my idea:

According to most data, not expanding Medicaid in North Carolina is affecting approximately 1.6 million uninsured North Carolinians. But to my point of the shortage of health care providers accepting Medicaid, what is the point of having an insurance card that no health care provider accepts? Therefore, I propose a pilot program here in NC…a pilot program to help the approximate 1.6 million uninsured in NC. Besides the moral issue that everyone deserves quality health care, fiscally, it is sound to provide the uninsured with quality health care (notice that I did not say to provide the uninsured with Medicaid). When the uninsured go to emergency rooms it costs the taxpayers more than if the uninsured had an insurance policy that would allow primary care and specialty doctor appointments. But with Medicaid…you can count out most specialty care, even some basic necessary care like dental care.

Most of the uninsured in NC are non-disabled men. I say this because it is usually easier to get a child on Medicaid with the Early, Periodic, Screening, Diagnostic, Testing (EPSDT) laws. See my blog: “How EPSDT Allows Medicaid Recipients Under the Age of 21 To Receive More Services Than Covered by the State Plan” for an explanation of EPSDT. Many women receive Medicaid based on having dependent children. “In most states, adults without dependent children are ineligible for Medicaid, regardless of their income, and income limits for parents were very low—often below half the poverty level.” See Kaiser Foundation. Which means, generally, many of our uninsured are men without dependents. However, that does not mean they are not fathers. Many of the uninsured are fathers.

Two-thirds of the uninsured live in families where there is at least one full-time worker. However, the percentage of uninsured who live in families with no workers, part-time workers and only one full-time worker has increased 12 percentage points over 5 years. See Demographics.

So how do we help the uninsured without merely handing all uninsured a Medicaid card that will not give them quality health care because not enough trained health care providers accept Medicaid patients?

By giving the uninsured health care insurance, of course! But not Medicaid coverage…oh, no! By giving the uninsured private insurance that will be accepted by all health care providers, all specialists, all durable medical equipment companies, all dentists…

We could partner up with a larger insurer like Blue Cross Blue Shield (BCBS) and create a premium health care insurance on which the insured would pay no premiums or co-pays. Instead, federal grant money would cover the premiums. All that money that NC did not receive based on our decision to not expand Medicaid…can go toward this pilot program to purchase the private insurance for the uninsured.

In order to qualify for this premium, free, private insurance the person must:

1. Be a legal resident;
2. NOT qualify for Medicaid; and
3. Maintain a part time job.

The reasoning behind the criterion of maintaining a part-time job is simple.

It is indisputable that the Affordable Care Act (ACA) has motivated employers across America to decrease the number of full-time jobs due to the mandatory expense of employers providing health care to full-time employees.

Obviously, part-time work does not pay well. It is difficult to even maintain a living on part-time work’s low hourly wages. Many people are forced to hold down two-part time jobs in order to survive. If you can not work and receive more government hand outs, what is the incentive to work?

If my idea comes to fruition and many of our uninsured carry a private insurance card and receive quality health care from the providers of their choice, we could create a whole new group of North Carolinians not only contributing to the community by working, but also contributing to their own homes, and improving themselves and those around them.

I don’t want to provide anyone a useless piece of paper that does not provide quality health care. We may as well give everyone a “proud cut” horse that no one could ride.

Thank you, Congresswoman Renee Ellmers, for being willing to listen to me regarding the uninsured and actually follow-up with the intent to implement.

Quality health care is imperative. Necessary. Needed. We need to fix this system.

“Thank You, Providers Who Accept Medicaid!” From: Me

During this holiday time of giving and family time, I would like to take a moment to say, “Thank you!” to all you health care providers who accept Medicaid. 

Thank you!!

It’s not easy to be a Medicaid provider, especially in our current Medicaid landscape.  It’s also not immensely profitable.  But, there are still approximately 70,000 of you in NC continue to accept and serve Medicaid recipients despite the rocky terrain.  And, I, for one, would like to say, “Thank you!”

More so than private insurances, and, I daresay even more than Medicare, accepting Medicaid patients places a large burden on the Medicaid providers. At least in Medicare, the reimbursement rates are higher.  Because the number one complaint I hear from health care providers is the Medicaid reimbursement rates SUCK! And they do!

For example, for CDT code D0120, which is a periodic oral exam, a dentist is reimbursed $25.27.  For a physician, an office visit emergency care is reimbursed at $18.20. Home health care medical supplies are also reimbursed at a law rate.  For 10 mL of sterile water Medicaid reimburses 41 cents.  (I didn’t realize that my computer does not have a symbols for “cents.”) An intermittent urinary catheter; straight tip, with or without coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.) is reimbursed at $1.59.

My point is that, no matter what type of provider you are, a dentist, a physician, and a home health provider, if you accept Medicaid, you also have overhead costs (rent, electricity, perhaps cable), plus staff costs (salaries, taxes), plus other incidentals (office furniture, decoration, supplies) and you hope to make a profit.  Therefore, many health care providers simply do not accept Medicaid because the reimbursement rates are so much higher if they only accept private insurance, or even Medicare.

 Not to mention the federal and state regulations that you have to follow if you choose to accept Medicaid….Oh, and, by the way, if you fail to follow any regulation, you may be subject to an audit.

Oh, and, by the way, even if you DO follow all applicable rules and regulations, you are still subject to audits.

Instead of sending a Tentative Notice of Overpayment (TNO), a notice of an upcoming audit, some crappy reimbursements during this holiday season, I would like to send a big “Thank You!” to all the health care providers in NC that accept Medicaid.

Thank you!!

In the Future, Could Physicians Be Forced to Accept Medicaid?

According to a report in the “Mason Conservative,” Virginia Democrat delegate candidate, Kathleen Murphy, stated, during a debate, that the government should force physicians to accept Medicaid.

After reading that, how many of you shuddered from horror?

I think we can all agree that we need more physicians to accept Medicaid.  We simply do not have enough physicians to meet the needs of all our Medicaid recipients.  Not enough physicians equals not enough quality health care to our most needy.  In particular, rural areas suffer most from the lack of physicians who accept Medicaid.

According to Forbes magazine, “Right now, the United States is short some 20,000 doctors, according to the Association of American Medical Colleges. The shortage could quintuple over the next decade, thanks to the aging of the American population — and the aging and consequent retirement of many physicians. Nearly half of the 800,000-plus doctors in the United States are over the age of 50.”  I’m sure Forbes would have found even more shortage had it researched the rural areas.

But is the answer to force doctors to accept Medicaid?

A week or so ago I saw my primary care physician.  I’ve seen my primary care doctor for years. (We will call him Dr. Bob).  He’s a native North Carolinian, just like I.  So he knew me in college, law school, and for the past 13 years of my legal career, both pre-baby and post-baby.  Until a week or so ago, I always knew Dr. Bob accepts Medicaid as a form of insurance.  I liked that he did.

Per our normal routine, Dr. Bob asks about my husband, my daughter, and my job.  But, usually he is extremely interested in “all-things-Medicaid.”  He normally asks the status of reimbursement rates, my opinion on the current administration, my perception of the trend at my job (who was getting audits, who may be getting audits soon, etc.), and other various Medicaid-related issues.

But, at my visit, Dr. Bob fails to ask about the current events of Medicaid.  And I, being I, just started talking about Medicaid.  He interrupts me and says, “Knicole, I made a difficult decision since I have seen you last.”

Pause….I’m expecting:

Retirement….possible divorce???

Retirement….change in profession???

Retirement…closing his practice???

Instead, Dr. Bob says, “I’ve decided to no longer accept Medicaid.”  (My jaw is agape).

My first instinct is, “What? But you CARE! How could you?”

My second instinct is, “I get it. Medicaid is a hassle.”

My third instinct is to actually ask HIM why HE made this decision. (My first couple instincts are usually the wrong route).

When I ask him why he decided to no longer take Medicaid, his response is “I’m sick of people who are not physicians telling me what to do in my practice.”

I get it. 

As a primary care physician, the bulk of his Medicaid work is conducting physicals (or what Medicaid calls, “preventative care”).

He says that he is ‘ok’ with the low reimbursement rates of Medicaid because he is able to offset the low reimbursement rates by accepting more privately insured patients (like me).  He says he loves serving the Medicaid population. His issue lies in the administrative burden of accepting Medicaid versus accepting private insurance, including the regulatory audits, the way in which the regulatory audits are conducted, NCTracks debacles, and possible unannounced payment suspensions…to name a few.  Dr. Bob explains that when he decides a procedure is “gender-and-age-appropriate,” inevitably, someone, from some, state-contracted company, will come back to him a couple of years later to recoup the Medicaid money because that (non-physician) auditor disagrees that the procedure he chose, as a physician, was “gender-and-age-appropriate.”

DMA Clinical Policy 1A-2 defines preventative care as, “An adult preventive medicine health assessment consists of a comprehensive unclothed physical examination, comprehensive health history, anticipatory guidance/risk factor reduction interventions, and the ordering of gender and age-appropriate laboratory and diagnostic procedures.” (emphasis added).

He describes an audit during which an auditor, who was not a physician, attempted to recoup a date of service (DOS), citing the reason as the procedure was not “gender-and-age-appropriate.”  How can a non-physician decide what treatment is or is not “gender-and-age-appropriate?”

I’ve seen this before.  In behavioral health care audits, an auditor with no substance abuse clinical background determines no medical necessity exists for a service for a Medicaid recipient suffering from substance abuse.  In dental audits, an auditor without ever attending dental school, will determine that a partial implant is not medically necessary.

N.C. Gen. Stat. 108C-5 requires that, “[a]udits that result in the extrapolation of results must be performed and reviewed by individuals who shall be credentialed by the Department, as applicable, in the matters to be audited, including, but not limited to, coding or specific clinical issues.” (emphasis added).

Credentialed in the matters to be audited.

Is DHHS seriously credentialing non-physicians to audit physician? Non-dentists to audit dentists? Non-substance abuse clinical providers to audit substance abuse clinical providers?

I do not know whether DHHS is credentialing the auditors, but, in my experience, non-qualified auditors (in the field in which they are auditing) are conducting audits.

Going back to my original premise, are we going to force/require that physicians, in order to be physicians, to accept Medicaid, thus subjecting themselves to limitless and unannounced Medicaid audits? To force physicians to undergo the administrative burden that comes with Medicaid audits, not to mention the administrative burden to just follow Medicaid regulations?  To force physicians to accept the quite possible possibility that the physician will need to defend him or herself against audits and incur steep attorneys’ fees?

In Dr. Bob’s case, he did accept Medicaid for years.  Then, he consciously made the decision that he no longer wanted to be subject to the regulatory scrutiny that comes with accepting Medicaid.  So, now, would we force Dr. Bob to undergo the very scrutiny he so loathes?

It would be similar to the State forcing all attorneys to accept clients at a discounted rate and accept the threat of audits.  Or forcing accountants to accept clients at a discounted rate and accept the threat of audits.  Or forcing a plumber to accept clients at a discounted rate and accept the threat of audits.

Don’t we, in the United States, have the economic freedom to own private property, thus, logically, allowing us the right to pursue private property?

“We hold these truths to be sacred & undeniable; that all men are created equal & independent, that from that equal creation they derive rights inherent & inalienable, among which are the preservation of life, & liberty, & the pursuit of happiness;…”

See the Declaration of Independence.

I understand that Ms. Murphy’s comment was just that…a comment at a debate.  But her comment demonstrates that, while politicians understand there is a shortage of physicians who are willing to accept Medicaid, some politicians may believe that physicians should be forced to accept Medicaid.

But aren’t we all entitled to the economic freedom to pursue private property, happiness, and liberty?

Or is that all a ruse?