Category Archives: Medicaid contracts

Large Number of NC Mental Health Providers No Longer Accepting Medicaid

Since the onslaught of the Medicaid audits on NC health care providers who accept Medicaid, I have been curious as to how many providers have determined that they no longer wanted to accept Medicaid.  Most of my clients have mentioned the fact that after their current issue (whatever that issue is), they were not going to deal with Medicaid anymore.  They are sick of the erroneous audits, the difficulty in dealing with the MCOs, the pile of paperwork they have to provide to state agencies over and over due to post or prepayment review. They are done with Medicaid.

Why should we care whether these providers continue to accept Medicaid?

Let’s not lose sight of the Medicaid recipients.  All these MCOs, RACs and other state agencies are so hell-bent on saving/recouping money, that Medicaid recipients’ mental health care has been lost.  1.5 million North Carolinians rely on Medicaid for their insurance.  Yet, less than 60% of physicians/providers accept Medicaid.  Even less accept Medicaid when you get into specialized services (approximately 30% dentists in NC accept Medicaid).  We need the providers who are willing to accept Medicaid.  Medicaid recipients need providers who are willing to accept Medicaid.

This is not the first time providers have been squeezed out of the Medicaid system.  Remember back in January 2011, approximately 1800 mental health providers were squeezed out of the system with the implementation of CABHA.  All the Medicaid recipients that were seen by providers who were squeezed out, were forced to transfer to other providers.  Again, no apparent thought to the care of the Medicaid recipients.

Now, in 2012 and 2013 and beyond, more mental health care providers are being squeezed out due to Medicaid audits, prepayment reviews, post-payment reviews, and suspensions of Medicaid reimbursements (all of which are grossly incorrectly administered).

So what happens to the 1.5 million Medicaid recipients?  Somehow the Medicaid recipients’ needs are being lost.  MCOs are terminating good provider contracts; RACs are auditing good providers out of business.  The Medicaid recipients are not receiving services.

Until now, I have seen no data on the number of providers that have recently decided to no longer accept Medicaid.

Mecklenburg Psychological Association (MPA) has calculated the decrease in mental health providers in Mecklenburg County by analyzing changes in members insurance participation from 2011/2012 to 2013 ( 2011 & 2012 are combined).

The data do not indicate a reason as to why providers dropped their Medicaid participation.  And remember, this data only apply to Mecklenburg County.  But here is the data:

Insurance Participation Changes of MPA members from 2011/2012 to 2013
  2011 & 2012
Number of Members
None (take no insurance)
BC/BS State
NC HealthChoice
United Behavioral Health
Value Options
Medicaid Changes
No longer accept Medicaid
Moved – did not renew MPA Membership
Did not renew MPA Membership in 2013
New – members who accept Medicaid
MPA 3013 Non-renewers
No response
New Members 2013

Wow. In one county in NC, from 2011/2012 to 2013, 31 providers have opted to no longer accept Medicaid.

Makes you wonder where the Medicaid recipients are now that their providers no longer accept Medicaid.  I guess the Medicaid recipients’ needs are still lost.

Proposed NC Medicaid Bill: Circumventing the State Plan?

Proposed House Bill 320 will be heard in committee on Tuesday, May 14, 2013.

For those of you who do not know what House Bill 320-2013 is, let me explain:

As of now, when a health care provider’s Medicaid contract is terminated or suspended by a Managed Care Organization (MCO), the Office of Administrative Hearings (OAH), not superior court, has jurisdiction over the grievance.  OAH is the administrative court set up to hear grievances against a state agency. 

When North Carolina ceased DHHS’ issuance of a Final Agency Decision after the OAH decision back toward the end of 2012, North Carolina, in essence, was handing OAH a decision-making role in Medicaid.  The reason that any entity getting a decision-making role in Medicaid is so important is because the federal statutes specifically state that Medicaid must be run by a single state entity.  The fact that OAH had a decision-making role in Medicaid would violate the single state entity requirement.

So what did NC do in order to ensure compliance with the single state entity requirement set forth by the federal government?

NC asked the federal government for a Waiver.  Or, in other words, an exception.  NC asked the federal government, “Can we have permission to allow OAH to have a decision-making role and not be in violation of the single state entity requirement?”

The federal government authorized our request, which can be found as the State Plan, Attachment 1.1D.

Our State Plan, Attachment 1.1B states:

“OAH acknowledges and also agrees that the issue to be determined at final hearings conducted in accordance with this waiver is whether the single state Medicaid agency or one of its contractors or agents exceeded its authority or jurisdiction, acted erroneously, failed to use proper procedure, acted arbitrarily or capriciously, and/or failed to act as required by law or rule; that it will conduct de novo reviews in beneficiary.”

Therefore, according to our State Plan and the federal government’s authorization, OAH hears cases involving DMA and its contractors or agents.

Yet proposed House Bill 320 states, in pertinent part (at 108D-18(d), “Notwithstanding any other law, OAH does not have jurisdiction over any dispute between an LME/MCO and a provider or applicant.”

Obviously the State Plan and the legislature are at odds.  After receiving the authorization to do something by the federal government, can NC legislate around what the feds told us to do? Seems pretty hairy.  Personally, I would go with that whole Supremacy Clause stuff.

Proposed House Bill 320 would take the decision-making role regarding Medicaid away from OAH and simply hand the superior court the authority…with zero authority from the federal government.  This is like a teenage boy asking for permission to go to Billy Bob’s house, but really sneaking out to go see Betty Lou.

Well, Betty Lou, here we come…


ECBH Questioned at Town Hall Meeting: Why Are You Denying So Many Services??

East Carolina Behavioral Health (ECBH), one of North Carolina’s 10 MCOs had to defend itself at a local Mental Health Town Hall Meeting in Greenville, NC.

Amy Brown, who works at Arc of North Carolina, which is a company-advocate for people suffering from mental illness and/or developmental disabilities, finally asked what so many providers and recipients have been asking for months:


For the news video, click here.

“It appears that there is a growing trend of families being denied services,” Brown, who works at the Arc of North Carolina, told the panel.

Brown, like other families who have shared their story with 9 On Your Side, is frustrated with East Carolina Behavioral Health – the organization that manages local providers.

She says the processes ECBH requires to approve services for the mentally ill is long, tedious and ineffective.

“For those families that are willing to fight it out and go through the appeals process, it’s very frustrating, it’s very long,” Brown says.

ECBH, or any MCO, that denies medically necessary services, are denying Medicaid services for the most needy. 

But, believe me, this is NOT isolated to ECBH.  ECBH serves Beaufort, Bertie, Camden, Chowan, Craven, Currituck, Dare, Gates, Hertford, Hyde, Jones, Martin, Northampton, Pamlico, Pasquotank, Perquimans, Pitt, Tyrrell & Washington counties.  But medically necessary services are being denied outside the above-mentioned counties. 

Not only are medically necessary services being denied, but quality, competent health care providers are being DENIED Medicaid contracts or the Medicaid contracts are being rescinded.

People, listen, if a health care provider resides in Beaufort county, NC, that health care provider, in order to provide mental health services to the Medicaid population must contract with ECBH in order to provide services.  There is no other option.  The provider cannot, for example, just contract with a different MCO, to provide mental health services within Beaufort county.  ECBH is  the only option in Beaufort county for a Medicaid contract in behavioral health.  So, if ECBH, arbitrarily decides that it does not want to contract with Provider X, for whatever reason, Provider X cannot provide mental health services to Medicaid recipients within Beaufort county and be reimbursed for services rendered. Period.

And this is happening. Providers, who have been providing mental health services to Medicaid recipients for, sometimes, years and years, and who have, some, hundreds of Medicaid recipients, are being denied a Medicaid contract with ECBH, and other MCOs, are not receiving the reimbursement for services rendered for themselves and their staff, and are being forced to close their doors or no longer accept Medicaid patients.

The MCOs, including ECBH, seem to be pushing mental health care providers away from Medicaid, resulting in Medicaid recipients not receiving desperately-needed mental health services.

And here I thought mental health is such an important topic…

It’s easy to proclaim that you care about providers and recipients and you want Medicaid recipients to receive quality health care, but it’s a whole other thing to actually determine if the WAY the system is IMPLEMENTED is broken.  Maybe it’s not the Medicaid system that is broken; maybe it is the implementation of the system.

George Bernard Shaw said, “People who say it cannot be done should not interrupt those who are doing it.”

NC Medicaid Providers: Does Your Insurance Cover Legal Fees for Regulatory Audits??

I must confess…I do not know much about health care providers’ liability insurance.  I just haven’t had to deal with liability insurance many times.

But, a client has recently informed me that their liability insurance will compensate them for 100% of my attorney fees that pertain to my representation germane to their regulatory audit. If this is true, then I have many clients that need to have a chat with their insurance companies.

Please understand…I have NOT read the small print with this insurance coverage. I do NOT know the ins and the outs of this insurance, or, even, whether it will actually, truly cover 100% of attorneys fees.

But, IF there is a possibility of your insurance company covering attorneys fees, what is there to lose?

This is all I know:

Alleged insurance that covers legal fees for regulatory audits? “APA Plus.”

From what I understand, if you pay an extra $15/month, the insurance will cover legal fees associated with regulatory audits, up to $50,000.

Again, please understand, this is hearsay, and I have read no insurance contract.  The ONLY reason I am blogging about an issue that I do not have verification of its veracity is because if, and only if, there is even a 1% chance that your insurance company will cover legal fees, this could be such a burden off your shoulders during such a stressful time anyway.

What does it hurt to try?

NC Medicaid Providers: Believe only half of what you see and nothing that you hear

Edgar Allan Poe said, “Believe only half of what you see and nothing that you hear.”

Not only do I think that Poe’s quote is accurate in every day life, but even more accurate as applied to dealing with the Division of Medical Assistance (DMA).

A client told me a story: (This is a synopsis. This may not be a true story.)

“I called DMA Program Integrity (PI).  The person there told me that my documents were fine and that I should not worry.  Two days later, DMA sent me a letter terminating my Medicaid contract.  And guess who signed it? The exact person who reassured me over the phone!”

Obviously, this client was flabbergasted when the letter of termination was delivered.  I try to logically understand how “client” could be reassured one day by DMA and two days later be terminated from Medicaid by DMA.

My question is: Is there a lack of communication between or within departments at DMA?

Logically, I see two options. I have not come up with any other options, but feel free to suggest any.

Option A: Perhaps the signator does not actually sign the documents; instead, maybe there is a stamped-signature for the signator. So, if a stamped-signature is used, perhaps the signator was unaware of the Termination Notice being mailed. But if the signator was unaware of something as important as a Termination Notice, then there is HUGE breakdown in communication, either between departments or within departments at DMA.

Option B:  So, if there is NOT a lack of communication between departments or within departments at DMA, then I am left to logically ascertain that the signator knew that the Termination Notice was being mailed or was going to be mailed at the time of the reassurance to client.

 Both Option A and B are bothersome.  I actually cannot decide which one is worse.

However, despite the reason behind both: (1) the verbal reassurance; and (2) the termination notice, the moral of the story is obvious: “Believe only half of what you see and nothing that you hear.”

Furthermore, despite the reason behind both, the action to be taken from the moral is: Document everything.

It reminds me of Aesop’s Fable, “The Man and the Satyr.”

A man and a satyr once poured out libations together in token of a bond of alliance being formed between them. One very cold wintry day, as they talked together, the man put his fingers to his mouth and blew on them. On the satyr inquiring the reason of this, he told him that he did it to warm his hands, they were so cold. Later on in the day they sat down to eat, the food prepared being quite scalding. The man raised one of the dishes a little towards his mouth and blew in it. On the satyr again inquiring the reason of this, he said that he did it to cool the meat, it was so hot.

“I can no longer consider you as a friend,” said the Satyr, “a fellow who with the same breath blows hot and cold.”

Medicaid Jurisdictional Questions? Answer is OAH, OAH, OAH!!

Jurisdiction…ugh…what a dry, boring topic.  But wait!! Legal jurisdiction is imperative information for all my health care provider readers. Let me explain:

  • Say you disagree with a Medicaid denial of services for one of your patients; or
  • Say you disagree with the denial of your Critical Access Behavioral Health Agencies (CABHA) certification; or
  • Say you disagree with being placed on prepayment review or undergoing a post-payment audit.

In what venue do you have to legally pursue the claim?  Right now, some DMA-contracted companies are claiming that OAH does not have jurisdiction over them. In fact, I even have an Order signed by a Judge directing the contracted company to act, yet the company argues that OAH has no control over it.  However, the State Plan states differently….

The Office of Administrative Hearings (OAH) has jurisdiction (meaning OAH can hear lawsuits against) state agencies.  “Agency” is statutory defined as an agency or an officer in the executive branch of the government of this State and includes the Council of State, the Governor’s Office, a board, a commission, a department, a division, a council, and any other unit of government in the executive branch. A local unit of government is not an agency.

The state court system, instead is for civil actions.  The district court division is the proper division for the trial of all civil actions in which the amount in controversy is ten thousand dollars ($10,000) or less; and the superior court division is the proper division for the trial of all civil actions in which the amount in controversy exceeds ten thousand dollars ($10,000).

Whether you are required to proceed legally at OAH or state court will impact your claim A TON!

The OAH Mission Statement is:

To serve the citizens of North Carolina, with quality and efficiency, by providing an independent forum for prompt and impartial resolution of administrative law contested cases involving citizens and state agencies; investigating alleged acts of unlawful employment practices in state government; functioning as the State’s codifier and publisher of all administrative rules; and reviewing rules before the Rules Review Commission.

Daily, OAH decides cases against the state government.  Therefore, the judges at OAH are intimately involved in state legislation and the state governments limits.  Also, OAH is a much faster process.  A Contested Case Hearing filed in OAH will be heard in months (a preliminary injunction, even quicker); whereas a complaint filed in Wake County Superior Court may not be heard for years (it may be faster or slower in rural areas. I just don’t know).

From my cursory explanation of OAH, it would appear that any Medicaid issue against the state government would automatically be heard at OAH, right? Well, recently, I have encountered a number of Division of Medical Assistance’s agents arguing that (1) these agents are not agents, they are independent contractors; and (2) that OAH does not have jurisdiction over the agents.

Specifically, DMA contracts with companies to manage Medicaid, conduct audits, conduct investigations, etc.  The Managed Care Organizations have been contracted with DMA to manage Medicaid behavioral health.  Remember, since Western Highlands was consumed by Smokey Mountain, North Carolina now has 10 MCOs.  They are, in no particular order:

  • Coastal Care
  • East Carolina Behavioral Health
  • Alliance Behavioral Health
  • Cardinal Innovations HealthCare Solutions
  • CenterPointe Human Services
  • Smokey Mountain Center
  • Partners Behavioral Health Management
  • Sandhills
  • MeckLink Behavioral Healthcare
  • EastPointe

So what if you have a legal disagreement with an MCO? State court or OAH?  So far, all MCOs have declared themselves to be out of OAH jurisdiction.

However, remember my blog, “Final Agency Decision No Longer Needed in Appeals” from March 5, 2013? If not, feel free to go back and read it.

The point is, unless North Carolina receives a specific Waiver from the federal government, NC must follow federal law which requires a single state agency to administer Medicaid. If OAH is allowed a final decision, then, in essence, another entity is deciding a Medicaid issue.

So, is NC in violation of federal law? Well, yes, as to other federal laws, but not in this case.  NC submitted a State Plan Waiver, which was granted on December 27, 2012.

The Waiver states, in pertinent part, OAH acknowledges and also agrees that the issue to be determined at final hearings conducted in accordance with this waiver is whether a single state Medicaid agency or one of its contractors or agents exceeded its authority or jurisdiction, acted erroneously, failed to use proper procedure, acted arbitrarily or capriciously, and/or failed to act as required by law or rule…”

According to the Waiver, it does not matter if the MCO is a contractor or agent. Either way, OAH has jurisdiction.

2013 Health Care Today: Knicole C. Emanuel Will Be a Panelist as Medicaid Expert

For anyone interested, the Triangle Business Journal, is hosting a Health Care symposium discussion, which will mainly revolve around the issues affecting employers, health care providers, insurance and benefits consulting companies as everyone gets ready for the implementation of federal health care law in 2014.  I am sitting as a panelist for the discussion.

Here is the link:

Here is a description:

2013 Health Care Today

How will the upcoming health care changes affect small businesses and their employees? Join us to find out!

  • When: Thursday, May 2, 2013,7:30am-9:30am Add to my calendar
  • Where: Sheraton Imperial4700 Emperor Blvd. Durham NC 27703

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  • Suggested Dress: Business

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2013 Health Care Today:  Your Impact, Your Dollars

How will the upcoming changes affect small businesses and their employees?

The symposium discussion will mainly revolve around the issues affecting employers, health care providers, insurance and benefits consulting companies as everyone gets ready for the implementation of federal health care law in 2014.

Moderator:  Triangle Business Journal Health Care Reporter Jason deBruyn


  • Dr. Allen Dobson, President and CEO of Community Care of North Carolina
  • Rick Kelly, Senior Vice President of Progressive Benefit Solutions
  • Adam Searing, Director of Health Access Coalition for the North Carolina Justice Center
  • Brad Wilson, President and CEO of Blue Cross and Blue Shield of North Carolina
  • And me:) Knicole C. Emanuel, Medicaid Attorney

More panelists to be announced soon…

Join Triangle Business Journal as a panel of experts discuss these very important changes in the health care rules that could have a profound impact on our economy.

NC Medicaid and Constitutional Due Process

Due process.  What is due process? We hear the phrase due process constantly in the media, in movies, in everyday vernacular…but what is “due process?” And is due process germane to Medicaid contracts?

Due process is part of our Constitution’s fabric.  Thomas Jefferson, one of our founding fathers, drafted the passage in the Declaration of Independence that states “all men are created equal…” there are “unalienable rights…” including “life, liberty and the pursuit of happiness.”  He influenced the Due Process Clauses of the Fifth and Fourteenth Amendments, which provide that no person shall be deprived of “life, liberty, or property without due process of law.”

For a definition of due process, I am going to utilize the wonderful website of “Wikipedia.” Few websites have such a broad-defining ability and its definition of due process and the importance thereof is great:

“The Fifth and Fourteenth Amendments to the United States Constitution each contain a Due Process Clause. Due process deals with the administration of justice and thus the Due Process Clause acts as a safeguard from arbitrary denial of life, liberty, or property by the Government outside the sanction of law.[1] The Supreme Court of the United States interprets the Clauses however more broadly because these clauses provide four protections: procedural due process (in civil and criminal proceedings), substantive due process, a prohibition against vague laws, and as the vehicle for the incorporation of the Bill of Rights.”

Legally, the key components to due process is “denial of life, liberty or property.”  In order to trigger due process, you have to prove that whatever is being taken from you is a denial of “life” “liberty” or “property.”  For example, if you argue that a policeman cannot take your license from you without due process, the answer is, yes he or she can because driving is a privilege, not a right.

So is a Medicaid contract a right? Or a property right? A property right that requires due process prior to termination?

There are a number of ways to argue this.  Of course, one argument is, no, a Medicaid contract is a privilege not a right. I’m sure that the Division of Medical Assistance (DMA) would argue the former.  However, I disagree.  I also think that federal law would disagree (if it could speak).

In order to receive federal funding for Medicaid, North Carolina is required to submit a State Plan under Title XIX of the Social Security Act.  The State Plan defines the scope of Medicaid and presents “promises” to which NC agrees to adhere.  Part of the State Plan is adhering to all pertinent federal statutes, regulations, as well as  including adherence to the Constitution of the United States.

Our State Plan states, in pertinent part, that it promises that “The State has an adequate appeal process in place for entities to appeal any adverse determination by the Medicaid RACs.”

Yet, N.C. Gen. Stat. 108C-7 states, in pertinent part, “[t]he decision to place or maintain a provider on prepayment claims review does not constitute a contested case under Chapter 150B of the General Statutes. A provider may not appeal or otherwise contest a decision of the Department to place a provider on prepayment review.”

How does our State Plan promise an appeal process while the NC Gen. Stat. states no appeal is allowed? It would appear to me that the State Plan and NC Gen. Stat. 108C-7 are at odds.

Let’s set the stage:

The RACs are the Recovery Audit Contractors that manage the audits and exploration of prepayment reviews for a health care provider. In North Carolina, the RACs are the Carolinas Center for Medical Excellence (CCME), Public Consulting Group (PCG, and HP Enterprises (HP).

Prepayment reviews are reviews on certain types of claims that historically result in high rates of improper payments. These reviews will focus on seven states with high populations of fraud- and error-prone providers (FL, CA, MI, TX, NY, LA, IL) and four states with high claims volumes of short inpatient hospital stays (PA, OH, NC, MO) for a total of 11 states.

While on prepayment review, the health care provider may not be reimbursed for Medicaid services rendered until “the provider achieves three consecutive months with a minimum seventy percent (70%) clean claims rate.” (See N.C. Gen. Stat. 108C-7(f)).

Those withholdings of Medicaid reimbursements, I argue, meet the standard of “property.” I would also argue that the withholding of Medicaid funds without due process constitutes “illegal state action” (see below) if the provider can prove that the prepayment review is conducted erroneously.

Theoretically prepayment reviews are designed to catch Medicaid fraud.  In reality, the prepayment reviews are overbroad and threatening the very existence of quality health care providers.

So, are the RACs’ withholding of Medicaid reimbursements for services rendered a deprivation of “life, liberty or property?”

In the Supreme Court case, Wilder v. Virginia Hospital Association, in 1990, the Supreme Court held that providers also had a private cause of action under Section 1983 against illegal state action.

Arguably, North Carolina’s implementation and enforcement of N.C. Gen. Stat. 108C-7 that refuses providers a right to appeal would be an illegal state action according to federal law.

Agree? Just haven’t had a chance to challenge 108C-7 yet.  There are so many arguments against its constitutionality.  But due process is one argument.

Prisons and Emergency Rooms: Our New Medicaid Mental Health Care Providers?

Emergency rooms and jails are our mental health care providers for Medicaid recipients?

My best friend is an ER trauma nurse.  She told me that a majority of patients are mentally ill.  One man came in to the ER, screaming at the top of his lungs, “Get me my lilly pad!”  Apparently he believed that he was a frog.  While you may smile at the humorous notion of the lilly pad man, it is a sad tribute to the state of mental illness in North Carolina.  Why was he not getting the care he needed?

And here I  thought mental health care was so important. In light of recent events, I would venture to say that mental health is quickly becoming our nation’s most pressing issue.

First let me say, Boston…so tragic.  My prayers are with all families affected by the bombing.

So you would think with all the hoopla in the aftermath of the Boston bombing and other serious heinous acts (Connecticut) that our mental health system would be top priority.

Is there a correlation between poor mental health systems and violent crime? Yes.

Here are some studies:

  • The present study of public psychiatric beds in the United States suggests that 42 of the 50 states have less than half the minimum number of beds considered to be reasonable by knowledgeable experts. In 32 of the states, the shortage is critical or severe.
  •  A study in Ohio compared 122 patients with schizophrenia who had committed violent acts with 111 patients with schizophrenia who had not committed such acts. The violent patients had significantly more prominent symptoms and significantly less awareness of their illness. Friedman L, Hrouda D, Noffsinger S et. al. Psychometric relationships of insight in patients with schizophrenia who commit violent acts. Schizophrenia Research 2003;60:81.
  • A study of 961 young adults in New Zealand reported that individuals with schizophrenia and associated disorders were two-and-one-half times more likely than controls to have been violent in the past year. If the person was also a substance abuser, the incidence of violent behavior was even higher. Arseneault L, Moffitt TE, Caspi A et. al. Mental disorders and violence in a total birth cohort. Archives of General Psychiatry 2000;57:979–986.
  • A study of 63 inpatients with schizophrenia in Spain reported that the best predictors of violent behavior were being sicker (i.e., higher scores on symptom measures) and less insight into their illness. “The single variable that best predicted violence was insight into psychotic symptoms.” Arango C, Barba AC, Gonzalez-Salvador T et. al. Violence in schizophrenic inpatients: a prospective study. Schizophrenia Bulletin 1999;25:493–503.
  • A 10-year follow-up of 1,056 severely mentally ill patients discharged from mental hospitals in Sweden in 1986 reported that “of those who were 40 years old or younger at the time of discharge, nearly 40 percent had a criminal record as compared to less than 10 percent of the general public.” Furthermore, “the most frequently occurring crimes are violent crimes.” Belfrage H. A ten-year follow-up of criminality in Stockholm mental patients. British Journal of Criminology 1998;38:145–155.
  • A study of 331 individuals with severe mental illness in the United States reported that 17.8 percent “had engaged in serious violent acts that involved weapons or caused injury.” It also found that “substance abuse problems, medication noncompliance, and low insight into illness operate together to increase violence risk.” Swartz MS, Swanson JW, Hiday VA et. al. Violence and severe mental illness: the effects of substance abuse and nonadherence to medication. American Journal of Psychiatry 1998;155:226–231.

What about North Carolina? Where are our mentally ill? In jails? Hospitalized? Or receiving quality mental health care.

The study “More Mentally Ill Persons are in Jails and Prisons…” states, “Using 2004–2005 data not previously published, we found that in the United States there are now more than three times more seriously mentally ill persons in jails and prisons than in hospitals. Looked at by individual states, in North Dakota there are approximately an equal number of mentally ill persons in jails and prisons compared to hospitals. By contrast, Arizona and Nevada have almost ten times more mentally ill persons in jails and prisons than in hospitals. It is thus fact, not hyperbole, that America’s jails and prisons have become our new mental hospitals.”

Having a strong, competent, and easily accessible system to serve those people suffering from mental illness is key to so many things you would want in a society: (1) those suffering from mental illnesses would receive the quality health care so needed; (2) there would be less homeless; (3) there would be less violence (see above-referenced studies).

Now, since this is a Medicaid blog, I will obviously concentrate on the Medicaid population.

So what is North Carolina doing regarding the mental health system for Medicaid recipients?

With the implementation of the Managed Care Organizations (MCOs), the hiring of Recovery Audit Contractors (RACs) and the utter lack of supervision by the Division of Medical Assistance (DMA), the Medicaid mental health system is spiraling downward.

Medicaid recipients are not receiving the care needed because of the state’s, MCOs’ and RACs’ treatment of health care providers willing to accept Medicaid.

Here are some serious and real-life examples:

1. The MCOs are denying authorizations for more expensive mental health services.

In a certain county, a certain MCO is denying all ACTT services, stating the Medicaid recipients do not meet eligibility requirements. ACTT, or Assertive Community Treatment Team services.  ACTT is a 24-hour, 7 day/week service for the seriously mentally  ill. Since the MCO denied ACTT services in this certain county, despite medical necessity, 2 discharged ACTT recipients have committed crimes and become incarcerated. One discharged recipient attempted suicide. Two in jail; one in a hospital.  Thank you, new mental health care providers.

2. The RACs are causing quality health care providers who have never committed fraud to have their Medicaid contracts terminated based on paperwork nit-picking and causing Medicaid recipients to lose their provider.

One such provider serves teen-age boys suffering mental illnesses with violent tendencies. With its Medicaid contract terminated and the inability to pay its staff, those boys may soon be homeless and on their own. The consequences could be catastrophic. Jails and hospitals, I am sure.

What is DMA doing about the MCOs denying medically necessary services and the RACs terminating health care providers needlessly and erroneously?


DMA states that MCOs and RACs are independent contractors; therefore, DMA cannot supervise the MCOs and RACs. I say, “Hog-wash.” DMA cannot divorce itself the duties of managing Medicaid.

But, regardless, stop pointing fingers.  Who cares if its DMA’s fault that the teenage boys receiving residential Medicaid services will be homeless because the RACs erroneously and without due process terminated the provider’s contract? Just fix it. Period.

Stop the jails and emergency rooms from becoming North Carolina’s mental health care providers!

More Audits, Less Health Care Providers Who Accept Medicaid!

In my profession, I come across so many health care providers…of all sorts….dentists, psychiatrists, speech therapists, general practitioners, etc. Many of these providers and most of my clients, despite the audits, despite the immense paperwork, despite the low reimbursements, despite the lack of communication with the Division of Medical Assistance (DMA) and all agents, most providers still want to serve Medicaid recipients, even after the horrible events the providers are dragged through.

But, today, I had two potential clients receive a consultation.  When I asked, “Is your goal to get your Medicaid contract back?” Potential clients answered (paraphrasing), “Heck no!!!!”

These potential clients were quality health care providers.  Like so many other providers, these potential clients committed no fraud.  All they did was provide quality health care services to Medicaid recipients and fell victim to paperwork nitpicking by DMA and agents (Managed Care Organizations (MCOs) and Recovery Audits Contractors (RACs)).

But these potential clients were sick of it. They were continuing their practices, but without Medicaid recipients.  So when they open their doors and Medicaid recipients come for help, there will be two more health care providers saying, “Sorry. We don’t accept Medicaid.”

Recently, I have watched Gov. McCrory and Director Wos in interviews.  I seem to remember Director Wos saying, in an interview, that she wanted North Carolina to be the best place for providers to practice health care and accept Medicaid.

I think, if memory serves me right, that part of making providers want to accept Medicaid recipients in NC, would be to not harass providers by conducting audits in a an erroneous manner (by contracting out to minimum wage,  non- knowledgeable “contractors”), would be to not terminate Medicaid contracts without due process and without real cause, would be to not cause quality health care providers to force Medicaid recipients to be discharged from care.

If Gov. McCrory and Director Wos truly want to make health care providers want to accept Medicaid in NC, (which I actually believe) then what about what is happening right now?? I understand that, in the future, providers may be happy in NC, but, right now, providers are losing their businesses because of ridiculous audits with ridiculous outcomes.  We are worried about providers NOW.  I beg of all politicians with pull to save these Medicaid providers, please use that pull now.  One week from now, 3-9 providers could be out of business. Two weeks from now, 6-18 providers could be bankrupt.

Worry about now. Fix now. Help these providers, before these quality providers go out-of-business.


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