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New Federal 10th Circuit Case Decision Warns Health Care Providers: Never Miss an Appeal Deadline!…Or Else!!
Yesterday, the 10th Circuit Court of Appeals reminded everyone in the health care arena of the importance of appeal deadlines. More so than other areas of law, the Medicaid world imposes short appeal deadlines with drastic repercussions.
In a published decision, Full Life Hospice, LLC, v. Kathleen Sebelius, Secretary, United States Department of Health and Human Services, 2013 WL 674756, U.S. Ct. of App., 10th Cir. (February 26, 2013) (only Westlaw citation available), the 10th Circuit Court of Appeals stated that Full Life Hospice, LLC (Full Life) failed to request a hearing within 180 days after notice of the final determination for Full Life to repay Medicare reimbursements that the U.S. DHHS claimed were distributed above the spending cap.
Now I understand that this recent decision covered Medicare deadlines and that North Carolina resides in the 4th Circuit Court of Appeals, but health care providers: BEWARE!!
Missing an appeal deadline will cause severe irreparable damage!!!
In Full Life Hospice, Full Life Hospice, a hospice care provider participating in the federal Medicare program, provided hospice care services to terminally ill Medicare beneficiaries and appropriately sought reimbursement for these services. In a later recoupment audit performed by a contracted agent of U.S. DHHS, (Sound Familiar?) the contracted agent demanded repayment of funds that it claimed were distributed in excess of a Medicare spending cap.
The Medicare Act allows for challenges to regulations such as 42 C.F.R. 418-309, but it establishes a specific procedure for bringing such claims. As is relevant here, this process can begin with a hospice provider’s challenge to the basis for a request for repayment made by an HHS fiscal intermediary.
A provider is required to file a request for such a hearing with the Board “within 180 days after notice of the intermediary’s final determination.” Id. § 1395oo(a)(3).
Because Full Life Hospice failed to request a hearing within 180 days, the 10th Circuit Court of Appeals found that it had no subject matter jurisdiction.
Now, here in NC, in Medicaid, the appeal deadlines are even faster.
Deadlines:
Appeal a Tentative Notice of Overpayment: 15 days. The result of failing to appeal within 15 days? The Tentative Notice of Overpayment becomes a final decision. Period.
Appeal a DHHS Hearing Officer’s Decision: 60 days from the date of the decision. Failure to appeal within 60 days? Final Decision. Period.
What about a prepayment review, in which the statute does not allow an appeal? Wait until the 6 months pass and see whether you get off prepayment review? No. If you do, expect a letter of termination from the Medicaid contract. Be pro-active. Seek help. Health care providers ate currently appealing these prepayment reviews and, alternatively, seeking injunctions.
Bottom line: Do not miss a deadline.
A Personal Account of a Medicaid Audit
Readers: I did not write the following blog. A gentleman emailed me his personal account of a health care provider undergoing a Medicaid audit. I asked for his permission to publish it and it was granted. (I apologize for any formatting issues.)
NOTE: The following is somewhat long but is a reflection of the recent topsy-turvy, sinusoidal, and duplicitous events in the NC Outpatient Mental Health setting…….
During the summer of 2012, while I was standing outside of a clinic where I contract waiting for my next client, a car rapidly pulled up and out jumped 4 stony faced people with briefcases and a purpose in their steps as they entered the clinic
It was an unannounced Medicaid audit.
Many clinicians and agencies knew these were occurring so it was not completely unexpected. At this particular free-standing private clinic which accepted Medicaid there was some anxiety (as any audit would produce) but we were pretty confident about our work – electronic medical records had fail safes for compliance, supervision occurred regularly, and the Clinical Coverage Policies for Medicaid were followed.
Over the next few months as the audit progressed a surrealistic Russian style bureaucratic nightmare occurred. Medical records were requested by the auditors and submitted by the clinic. CCME (Carolina Center for Medicaid Excellence) who was doing the audit would say ‘we didn’t get the records’ and be elusive and dodgy. Medical records were re-submitted – hand delivered. Feedback from CCME was that the Treatment Plans did not meet standards. The Treatment Plans were being developed in line with the posted Clinical Coverage Policy and they were also in line with the recommendations of one of the LME/MCO’s right over the county border but after much back and forth CCME continued to say they were not in compliance. CCME did not provide a clear indication of what compliance was nor did they provide a clear template for the Treatment Plans. (NOTE: The LME/MCO from the nearby county said the clinic’s Medical Records per their site review were at a 92.5% accuracy!!!)
Staff at the clinic worked diligently to cooperate with CCME but every attempt at cooperation was met with a shift of the carrot on the stick. Conference calls were scheduled, emails were written, repetitive requests for clarification were pursued without any success or resolve.
The clinic was then put on a “pre-payment review” meaning claims for services rendered were not paid until the records were reviewed and approved. ‘Pre-payment review’ is an unguided process that could take 30 days – the approval of records is based on unclear standards so any clinical services rendered were like the lottery – maybe they’ll get reimbursed if someone somewhere says documents meet some kind of unknown standards….or maybe they won’t get reimbursed at all.
Eventually, so much unproductive hoop jumping occurred and time was wasted that a deadline for acceptance by the local LME/MCO came due. Because of the delays by the CCME, the LME/MCO which went live on 2/1/13 said to the clinic ‘we can’t enroll you’ due to the ‘pre-payment’ status.
With only 3 days of lead time, over 100 clients – some of which were children in foster care or with PTSD or within the Juvenile Justice System – had to suddenly be terminated from treatment and referred to other agencies. Fortunately, the clinic will continue – contracted with the other county LME/MCO and accepting private insurance.
Was this top-down inefficient State bureaucracy? Was this effective Public Mental Health policy? Was there any consideration for how this would impact service provision and the clients? Was this purposeful – intended sabotaging of a clinic in order to reduce the number of providers within a community and save Medicaid dollars? Is this the CCME’s way of insuring ‘Excellence?’
I, and my colleagues who provide Public Mental Health services and who have weathered many pressures and changes, are not naive about accountability – we are ready to stand accountable and provide appropriate services with appropriate billing and documentation. I understand there are economic pressures at hand here but the current zeitgeist of audits, regulations and site reviews seems like a witch hunt and feels like a displacement for the past sins of others (http://www.inthepublicinterest.org/article/reform-wastes-millions-fails-mentally-ill). With the laser beam aimed at service providers – purposely geared to finding the smallest of errors in an effort to go ‘GOTCHA’ the zeitgeist is a culture of fear in order to insure accountability to DMA, CCME, DHHS, CMS, EDS, and the LME/MCO. Well what about accountability to our clients? Have policy makers forgotten about the clients in an effort to weed out the service provider playing field?
As a side note, it was rumored – and it may just be urban legend – that Medicaid auditors were paid based upon how much money they generated from the audit. If anyone has more information on this I would love to hear it – but at the community level it is understood that the contracted auditors were paid based upon how much money they were able to save Medicaid – how many claim denials they could find and how much money they were able to claw-back.
Wouldn’t this contractual arrangement be considered a kickback?….’the more money you save or make us the more you will get from us?’ Aren’t kickbacks considered illegal within the Medicaid and Medicare system?
Clinicians, Clinics and Agencies believe that there has been an INTENDED consequence with the tightening of regulations (such as CABHA and Medicaid Waiver) – the intention is the eventual reduction of the number of private agencies that provide outpatient Mental Healthcare. Both, agencies that do enhanced services as well as core services, are being purposely circuitously and indirectly liquidated. When looking at lists of agencies that accept Medicaid over time, there was a 50% reduction of agencies after CABHA. With the implementation of the Medicaid Waiver the list has dwindled even further. Initially LME/MCO’s have been accepting virtually all agencies that apply but it is anticipated that over the next year the bonsai tree will be trimmed even further with reviews of ‘outcome measures.’ More and more agencies will not be able to sustain. It is presumed that the final goal is to have a few large agencies contracted across the state.
Now, be advised that I have seen with my own eyes heinous service and billing improprieties in 2005 and 2006 and received backlash from profiteers when I called out inappropriate activities….so, I agree that it is necessary to set clear standards and hold providers accountable…HOWEVER, the zeitgeist is an over-rotation.
Let’s see how the pendulum swing, tightening of the noose and reduction of reimbursements is working….
One of the larger agencies that has satellite offices in 15 counties in the central NC area just closed two of it’s offices in 2 counties. In a different county where this large agency still has an office the pay for clinicians was cut, then cut again, then cut again, and a colleague of mine who works at this agency said that there were sweeping layoffis in her office. What is interesting is that many community clinicians believed this big multi county agency was one of the golden children that would sustain and still be standing while all the other ‘mom and pop’ or ‘pop up’ agencies were dissolved. Well, it seems like no one is immune anymore.
Another colleague of mine described how his multi county agency had radical re-structuring recently, specific Medicaid services were cut and the providers of those services were laid off, and there were across the board pay cuts.
Clinicians have no recourse either – ‘if you don’t like the pay cut then you can always try to find another job…wait…there are no other jobs since everyone else is closing so I guess you are stuck.’
On another side note, I recently head about a survey of private Psychologists who had been accepting Medicaid. The survey showed that over 40% of them intended to stop taking Medicaid clients due to the increase of regulations and requirements and reduction of reimbursements (all of which makes service provision cost and time prohibitive). Many of these surveyed Psychologists had over 8 years of experience – the intended consequence of reducing providers ALSO reduces your qualified and experienced professional base – these are the providers who know the clients and know the community and know the collateral resources.
I am aware of several private multi-county/multi-provider agencies that used to accept Medicaid clients but have stopped due to the cuts in rates and arduous regulations. What is interesting is that these private non-CABHA agencies provide excellent care, are preferred by clients, and ironically they bill a FRACTION of what CABHA agencies bill.
On February 1st a therapist from NC had an ‘opinion’ published in the Washington Post called:
“The risk of skimping on mental health funding”
Below is the link to this article which describes his frustrations with the Medicaid cuts in Southern Pines:
Since you may have to do a free ‘Register’ with the Washington Post online to see the article, here is an excerpt:
For mental health providers in North Carolina, 2013 marks another year of cuts to Medicaid reimbursement rates, which have declined steadily since 2008. States are responsible for a larger portion of mental health services than they are for physical services, which means mental health is hit hard by state budget negotiations. More than $4.3 billionhas been slashed from state mental health budgets nationwide since 2009, according to theNational Association of State Mental Health Program Directors. South Carolina, Alabama, Alaska, Illinois and Nevada are among the states that have had the deepest cuts.
The director of our clinic in Southern Pines, N.C., in the center of the state, has told me that this year’s cuts are likely to force us to close. Our facility offers mental-health and substance-abuse counseling to 75 to 100 clients a week, half of whom are 18 years old or younger. Typically, they are referred to us from child protective services, doctor’s offices or the local domestic violence/sexual assault agency.
When the events at the service delivery level are brought to policy makers’ attention, I deeply resent their disregarding platitude of “oh well….we know change is hard.” Well, it has been change (2001 divestiture and privatization), and change (2005 slashing community support), and change (2006 ValueOptions authorization policy changes) and change (2010 CABHA), and change (2012 Medicaid Waiver) and change (new billing and authorization systems such as Alpha and Provider Direct) and change (2013 Medicaid rates rates slashed 40% effective 1/1/13 then returned to prior rate on 1/23/13 with delays of payment for 1/13) and change (2013 CPT code changes and Medicaid rate and service time reductions)….You don’t know how many times I have had to say to clients “….I am sorry but there are NEW Medicaid regulations which will effect you in the following way…” You don’t know how many of my colleagues have said to me “….the agency where I was working closed….do you know who is hiring….”).
Furthermore, I resent the proverbial ‘pot calling the kettle black’ when Community Agencies, Individual Clinicians, and Private Practices accepting Medicaid are being scrutinized and audited to the point of being inoperable ALL THE WHILE there is waste and mismanagement at the top – DMA mismanagement (http://pulse.ncpolicywatch.org/2013/02/01/problems-identified-by-medicaid-audit-largely-result-of-nc-republicans-own-budget/), cost over runs with Computer Sciences Corporation (http://www.newsobserver.com/2012/06/17/2142627/state-contract-for-updating-computer.html), “structural flaws,” and more (http://www.wral.com/audit-mismanagement-costs-nc-medicaid-system-millions/12048026/).
I hope McCrory means what he says ( “We want to make sure that the money that’s supposed to help people is going to them, not to the administrative cost.”) and that ‘Medicaid Reform’ will have a positive result. I hate to be a ‘Negative Nick,’ but my fear (based on experience) is that if you squeeze on one side of the tube of toothpaste it gets smooshed (yes…a real word) to the other side….in other words, the ATTEMPT to reduce administrative waste may actually make its way down to the community level in the form of service and provider cuts. We shall see…..
I continue to provide services to Medicaid clients and IPRS clients through contracts with agencies, but it is unclear if I will be regulated out of the field. The Waiver continues….
Feel free to write back with your experiences, thoughts, and or comments.
Geoffrey Zeger, ACSW, LCSW
NC Health Care Providers Who Accept Medicaid: Thank you!
How about a big “Thank you” to our North Carolina health care providers accepting Medicaid?
Many providers continue to accept Medicaid despite the fact that the state is conducting Medicaid audits, the providers feel harassed by the state, the providers are terrified that they have to pay back hundreds of thousands of dollars for health care services actually rendered to Medicaid recipients, the providers are forced to wait months post-services rendered to receive Medicaid reimbursements, and the reimbursements are so much lower than the overhead costs.
Why? Why do health care providers undergo so much emotional and financial strain to provide health care services to Medicaid recipients? I believe that health care providers who dedicate services to Medicaid recipients truly understand and believe that the Medicaid population deserves and needs quality health care. These providers understand that most providers will not undergo the mental and financial stress needed to meet all the Medicaid criteria and documentation. So these providers feel a sense of duty to Medicaid recipients.
And to those health care providers who accept Medicaid in NC: “Thank you.”
I heard a story today of a health care provider who deserves this “Thank you,” and more. When the Personal Care Services (PCS) criteria changed this past January 1, 2013, many of the provider’s clients no longer qualified to receive PCS under Medicaid. Did that stop the provider from providing the needed PCS? No. Is the provider paid for its services? No. But this provider was dedicated to its clientele.
So when 80-year-old Dorothy (obviously, I have changed the names), who suffers from late-stage breast cancer, dementia, and Rheumatoid arthritis was told that she no longer met the PCS criteria, she was terrified. But this provider continues, even today, to provide Dorothy the care she needs.
The provider is not reimbursed for helping Dorothy. But the provider feels a sense of duty. Do you turn your back on someone in need because the General Assembly changed the PCS requirements? Or do you continue to help the person you have cared for for so many years and hope that the government will somehow right the injustice?
Interestingly, this same provider is undergoing two Medicaid audits for a total of approximately half a million in alleged recoupments. The provider was forced to hire an attorney and defend the Medicaid reimbursements it has received for years of providing quality health care service to the Medicaid population. Instead of getting a “Thank you,” the state has audited and claimed that the provider must pay back almost half a million dollars, even though the provider provided all the services for which it billed.
Yet this provider, not only provides all the services for which it bills Medicaid, but when Medicaid drops Dorothy (and thousands of others) from the Medicaid program, this provider goes above and beyond its call of duty and provides services knowing that Medicaid will never reimburse it.
Maybe this provider should not be audited. Maybe the Medicaid system should be audited for all the services for which this provider is not paid. Or maybe this provider, and many others, deserve a simple:”Thank you.”
NC Medicaid Eligibility: Now and Maybe
Medicaid eligibility. Just the phrase itself raises so many questions:
Am I eligible? Would I be eligible if NC expanded Medicaid? If NC does not expand Medicaid, does that mean I don’t have health insurance? What exactly is the income limit for a family of 4?
The Medicaid system, like our tax system, is esoteric. So, the purpose of today’s blog is set out some much-needed facts.
First, Medicaid eligibility, as of today, can be found in an extremely detailed, yet hard to understand, chart on the Department of Health and Human Services‘ (DHHS) website. Click here. But don’t say I didn’t warn you.
Under the federal health care law, should NC choose to accept the federal dollars, eligibility for government-backed Medicaid may be expanded in 2014 to anyone making below 138 percent of the federal poverty level. Here’s who would qualify:
Family size: Income level
1 person: $15,414
2 people: $20,879
3 people: $26,344
4 people: $31,809
So there is it: The Medicaid eligibility requirements currently and if NC accepts federal dollars.
It is important to note that, on Tuesday, February 12, 2013, Governor McCrory endorsed a measure to prevent major components of the federal health care law from taking effect in North Carolina. Merely hours after McCrory’s announcement, the measure won easy approval in a House committee. The full House will consider the legislation quickly.
I will devote another blog to the effects of reform versus expansion. Today, I only wanted to get the eligibility requirements out.
Go Directly to OAH! Do Not Pass DHHS!
Very rarely in the Medicaid arena will a health care provider be able to choose to advance to the Office of Administrative Hearings (OAH) without first visiting the Hearing Officers at the Department of Health and Human Services (DHHS). However, if ever given the choice, in the famous words of the Monopoly Man, “Go Directly to OAH! Do not pass DHHS! Do not collect your $200!”
When does a health care provider get this choice?
Never after receiving a Tentative Notice of Overpayment. But when a health care provider is placed on prepayment review and, subsequently, receives a Termination of Medicaid Contract notice, the provider may choose to (a) appeal to DHHS within 15 days; or (b) appeal to OAH within 60 days.
Why OAH?
1. Going straight to OAH skips a tedious procedural step (the reconsideration review):
Since I have practiced Medicaid law, I have never seen a decision from a DHHS Hearing Officer with which I agreed. Of all the DHHS decisions I have received on behalf of my clients, I have appealed 100%. Now, I am not saying that health care providers should not appeal if the only choice is DHHS. In fact, I strongly encourage the exact opposite. Because appealing to DHHS, in most circumstances, is just the beginning. Once the appeal is heard by a DHHS Hearing Officer and a decision in rendered, then a provider can move on to appeal to OAH. But, when given a choice between DHHS and OAH, always pick OAH because, basically, going straight to OAH allows the health care provider to skip a step.
2. Going straight to OAH costs less in attorneys’ fees:
Again, because going straight to OAH allows the health care provider to skip the reconsideration review at the DHHS level, attorneys’ fees are less.
3. Going straight to OAH appoints an Administrative Law Judge (ALJ):
If given the option between a DHHS Hearing Officer and an ALJ (not employed by DHHS), which would you chose to be the objective truth-seeker? I am in no way insinuating that the DHHS Hearing Officer is biased. I, personally, would just choose the person to hear my case who was not employed by DHHS. Plus, for the most part, ALJs are more sympathetic to Medicaid recipients and providers.
4. Going straight to OAH appoints an Attorney General (AG):
What? This is a good thing??? We WANT an attorney against us? Yes. Until the Medicaid recoupment appeal gets to the OAH level, there is no attorney on the state’s side. Which means no settlement can be discussed. Once an AG is assigned, the likelihood of settling skyrockets. The AGs understand the Medicaid rules and the benefits to settle. Thus, having a knowledgable attorney on the state’s side is extremely beneficial.
Despite all these great reasons to “Go Directly to OAH! Do not pass DHHS!,” inevitably, health care providers will normally not be able to skip DHHS. My advice? Appeal, Appeal, Appeal. And once you get the Decision from DHHS? Appeal, Appeal, Appeal. The decisions only get better once you receive that first DHHS decision.
Tips #9 and 10 for Avoiding Medicaid Recoupment
The most common statements I hear from health care providers when they are going through Medicaid audits is “I did not know THAT was required,” or “No one told us that we had to do THAT,” or, my personal favorite, “I called DMA and they told me we were doing THAT correctly.”
Tip #9:
First, if you call DMA, document the conversation in writing. Get the DMA representative’s name, title, and summarize the phone call in a safe place. Then write a letter to DMA summarizing the information you received.
Write something like this: “Per our phone conversation [DATE], you stated that [insert explanation, i.e., you stated that electronic signatures complied with NC Medicaid policy, if I take the following steps…]”
If you take this precaution, filing a note of the conversation and following-up with a letter, the you ensure that DMA cannot, later, deny the conversation. Remember, with oral conversations, no one remembers the conversation exactly the same.
Tip #10:
All health care providers, I venture to guess, at some point, needs to call DMA and ask a question. If so, follow Tip #9. But if you find that you or your employees often have questions, BE PROACTIVE.
Do not wait until the Medicaid audit to say, “I did not know THAT was required.”
How to be proactive? EDUCATE! Yourself and all your employees!
One of two ways:
1. Go on the DHHS website and find out when the State is giving educational seminars on Medicaid rules. And go to as many seminars as possible. While there, ask numerous questions;
or
2. Contact a Medicaid attorney (This is not an advertisement for myself, although I have done this for providers, but, please, research other Medicaid attorneys.) and have the Medicaid attorney come to your main office and give a presentation on Medicaid rules. If you go this route, make sure the Medicaid attorney understands what type of Medicaid services you provide, even better, tell the Medicaid attorney your specific concerns regarding your practice.
The upside about attending DHHS seminars is that the seminars are free. The upside of hiring a Medicaid attorney to come to your office, he or she can physically review some of your practices’ documentation for possible common mistakes.
Regardless, whatever you decide, do not do nothing until you received the Tentative Notice of Overpayment. It’s too late then. Be proactive in education.
Shortage of Dentists for Medicaid Recipients
I’ve blogged before about the shortage of dentists for Medicaid recipients. Just see my post “Medicaid Expansion: BAD for the Poor” to read about Deamonte Driver’s story and why he died due to not being able to find a dentist accepting Medicaid. But, today and yesterday, I decided to conduct my own personal investigation.
(First, let me assure you that this blog is not condemning dentists for not accepting Medicaid recipients. I am informatively (I know, not a word) pointing out the facts. We cannot expect dentists to accept Medicaid when the Medicaid reimbursements dentists receive cannot even cover their costs.)
I googled “Raleigh dentist” and called, randomly, 20 dentists listed. I said the same thing to each receptionist, “Hi. I was wondering whether you accept Medicaid.” Every office had a receptionist answer (no recording asking whether I wanted to continue in English or Spanish). Every office receptionist was very sorry, but the dental practice did not accept Medicaid. 0. Zero out of a random 20.
So I went on North Carolina Department Health and Human Services’ (DHHS) website for dental providers. I pulled up the dental providers, and, lo, and behold, 44 pages were full of dental providers for Medicaid recipients. Literally, 1,760 dental providers are listed (44 pages times 40 lines per page). (However, some practices are listed more than once, so this number is an approximation).
I thought, Wow. Tons of dentists in North Carolina accept Medicaid. Then I looked again. On the far right side of the chart, there is a space for whether the dental practice is accepting new clients. Roughly 1/2 of the listed dental providers are NOT accepting new Medicaid clients.
I called a few of the dentists in Wake County accepting Medicaid. Again, I asked whether they accepted Medicaid. One stated, “Yes, but not at the moment.” Another said, “Yes, but only for children 21 and under.” Another gave a blanket, “Yes.
So that’s Wake County…what about more rural counties?
I called a few dentists in Union County. Two practices did not answer. One dental practice answered and gave me a “Yes.” According to the DHHS chart of Medicaid-accepting dental providers, 20 dentists in Union County accept Medicaid. 4 of which are not accepting new clients and one dental practice is listed as the health department. There are no orthodontists in Union County accepting Medicaid.
The phone numbers for two dental providers in Swain County were changed or disconnected. There are only 3 dental providers in Swain County. There are no orthodontists in Swain County.
There is only 1 dental provider accepting Medicaid in Pamlico County. According to the DHHS chart, the one dental provider is not accepting new patients. There are no orthodontists in Pamlico County.
Polk County lists 3 dentists accepting Medicaid, but not one of the dentists are accepting new clients. There are no orthodontists in Polk County.
Mitchell County has 4 dental providers acccepting Medicaid. But 3 of those dental practices are not accepting new clients. There are no orthodontists in Mitchell County
In Clay County, the only dental practice accepting Medicaid recipients is the health department.
In Ashe County, there are 3 dentists listed that will accept Medicaid. Only 2 are accepting new clients, one of which is the health department. There are no orthodontists in Ashe County.
In Alamance County, there are 4 dentists listed by DHHS who will accept Medicaid patients. The first one I called (an orthodontist) told me that they accepted Medicaid patients only from certain general dentists. The second one was not accepting new patients. The third one (also an orthodontist) informed me that Medicaid does not cover orthodontia services for Medicaid recipients over 21 (I must sound old!!!) The fourth dental practice’s voicemail informed me that the office is only open Wednesdays and Thursdays for limited times. Of the 4 dental practices accepting Medicaid, 3 were orthodontists, one did not accept new clients. The only general dentist (pediatric) only practiced in the local office two days a week.
Shortage of dentists accepting Medicaid? You decide.
Mt. Gilead Group Home Closes Doors: So Many Questions Remain
Last week, a Montgomery County adult care home was forced to close down, causing dozens of adult, Medicaid recipients to be without health care or housing.
Owners Amy and Larry Patton had called the Department of Health and Human Services (DHHS) previously and informed DHHS that the slow Medicaid reimbursements were going to close down their facility.
There is very little information from the Pattons regarding the reasons the group home had to close, except for their complaints to DHHS regarding slow Medicaid reimbursements. It appears that they removed all valuable items from the Mt. Gilead, North Carolina group home, such as TVs and refrigerators, in the middle of the night. Employees came in the morning to find everything gone.
The residents and families of the residents in the adult care home are outraged, and rightly so. They should be outraged. But are they outraged at the correct people/companies?
As a Medicaid attorney, I see health care providers struggling every day to make payroll. The health care providers depend heavily on Medicaid reimbursements (a) being provided, and (b) being timely. If these Medicaid payments fail to come or fail to come timely, the health care provider, like any other business, is forced to close.
I have no evidence that Pattons were not receiving their Medicaid payment except for the complaint they made to DHHS regarding timeliness. There may have been more complaints. We will probably never know.
But it is a fact that there are health care providers in North Carolina which are not receiving Medicaid payments. In 2011, due to the Affordable Care Act (ACA) NC General Assembly passed Session Law 2011-399, which codified DHHS’ authority for pre-payment reviews. A pre-payment review places the health care provider in a situation that few providers are capable of overcoming. Basically, the Agency stops the medicaid payments to the provider until the provider can prove in 3 consecutive months that the provider can document a 70% accuracy rate based on the Agency’s standards.
According to NC Gen. Stat. 108C-7, the prepayment review can only last up to 12 months, at which time the provider will, most likely, lose its ability to serve Medicaid recipients if it is unable to meet the documentation requirements.
But 12 months without Medicaid payments will wipe out a health care provider.
Surprisingly, NC Gen. Stat 108C-7 does not allow a health care provider to appeal. No due process.
Now I have no evidence that the Pattons were subject to a pre-payment review. I have no evidence that the Pattons were not receiving Medicaid payments. But for a group care home to close its doors when the owners were not new to Medicaid (they also owned two other group homes in Guilford County), unexpectedly and without providing help to its Medicaid recipients is mysterious.
These were people trying to help Medicaid recipients. They owned 3 group homes. I question whether the Pattons, like so many other health care providers, were subject to pre-payment review with no appeal rights.
