We think too much; thus we fail to act. That’s what Hamlet was saying during his “To be or not to be” soliloquy, right? To live or not to live? Should you bear the painful burden of life or to refuse the burden by killing yourself?
Or does the fear of the unknown (death) make us bear our painful lives? (Although Shakespeare was much more eloquent).
Medicaid providers, how many times have you reviewed your own documentation only to find accidental scrivener’s errors? The service note failed to denote the correct date of service (DOS)…the Physician’s Authorization and Certification for Treatment (PACT) form cited an incorrect Medicaid number…or the CPT code on a service incorrectly indicated an individual treatment when the service was clearly a group treatment. (People, we are NOT talking about forgery or altering dates of a physician’s signature…these things would be considered FRAUD. We are merely talking about scrivener’s or clerical errors).
To revise or not to revise…that is the question!
And what an important question it is. Because, so easily, innocent documentation corrections could transmute into documentation fraud. Medicaid fraud. Criminal investigations. Bad!
A recent Office of Administrative Hearings (OAH) decision gives us some guidance on when to revise or when not to revise.
St. Mary’s Home Care Services, Inc. v. NC Division of Medical Assistance (DMA) Finance Management Section Audit Unit NC DHHS was signed January 8, 2014, by Administrative Law Judge Beecher Gray, who was recently appointed as a Special Superior Court Judge. Believe me, we will miss Judge Gray at OAH. His Order in St. Mary’s Home Care was his parting good-bye.
In St. Mary’s Home Care, the Department was seeking a recoupment of $4,334,056.09. One of the reasons for the recoupment was that the Department contended that St. Mary’s had violated “best practices” in the way it had amended PACT forms and service notes.
A witness for the Department testified that “best practices” required St. Mary’s to either create a new document or to strike through the corrected portion, enter the correction, sign the name of the individual making the correction, and append an explanation for the correction to the document.
Judge Gray disagrees.
“The Agency’s misunderstanding of the policy and use of unpublished “best practices” as a justification for its decision is erroneous, in violation of rule and law, exceeds the Agency’s authority, and is arbitrary and capricious.”
“The Agency failed to meet its burden of proving St. Mary’s violated clinical coverage policy when it made changes or corrections to PACT form plans of care.”
So when should you NOT revise?
Obviously, do not commit fraud. But, according to St. Mary’s Home Care, slight revisions to PACT forms and service notes will not be enough to warrant an overpayment.
“Go, bid the soldiers shoot.”
BNA’s Health Care Policy Report:
Posted March 5, 2014
The Obama administration March 5 said consumers can keep their health plans that don’t comply with the Affordable Care Act for two more years, as part of a release of new ACA rules and policies.
The Department of Health and Human Services noted that in fall 2013, the administration extended through 2014 noncompliant health plans in the small group and individual health insurance markets, for insurers that received permission from their state to do so. Now, the department is extending its “transitional policy for two years,” to policy years beginning on or before Oct. 1, 2016.
“This gives consumers in the individual and small group markets the choice of staying in their plan or joining a new Marketplace plan as the new system is fully implemented,” the HHS said.
The HHS also issued a comprehensive ACA insurance markets rule (CMS-9954-F) called the Notice of Benefit and Payment Parameters for 2015. The regulation includes provisions on premium stabilization; open enrollment for 2015; annual limitations on cost sharing; consumer protections; financial oversight; and the Small Business Health Options Program, or SHOP.
For the temporary “risk corridors program,” which helps stabilize premiums when enrollees are much sicker or much healthier than expected, the HHS said it intends to operate the program in a budget-neutral manner, with payments coming in equaling the amount of money going out, “while helping to ensure that prices remain affordable in 2015 and beyond.”
The Treasury Department and the Internal Revenue Service also released final rules (TD 9661) March 5 to implement the information reporting provisions for insurers and certain employers under the ACA that take effect in 2015. Treasury said the final rules on information reporting by employers “will substantially streamline reporting requirements for employers, particularly those that offer highly affordable coverage to full-time employees.” Treasury also released final rules (TD 9660) to provide guidance for reporting by insurers and other parties that provide health coverage under the ACA.
An HHS bulletin on the plan extension is at http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/transition-to-compliant-policies-03-06-2015.pdf. The HHS and Treasury rules are posted at the public inspection website: http://www.federalregister.gov/public-inspection.
By EMERY P. DALESIO, Associated Press
RALEIGH, N.C. (AP) — Gov. Pat McCrory’s health agency on Wednesday planned to unveil its latest version of ideas on how to change North Carolina’s $13 billion Medicaid health care system for about 1.7 million poor and disabled people.
The state Department of Health and Human Services was scheduled to present its framework for revamping Medicaid to an advisory group set up by McCrory. The plan could get some touch-ups before it’s presented to state lawmakers next month. The Legislature is expected to take up the proposed changes beginning in May.
It’s been almost a year since McCrory and state health Secretary Aldona Wos proposed largely privatizing management of Medicaid while keeping ultimate responsibility in state hands. About $3.5 billion of the shared state and federal program’s cost is paid by state taxpayers.
McCrory and Republican legislative leaders have blamed spiraling Medicaid costs left by preceding Democratic administrations for not providing teachers and state workers with raises last year. But Medicaid has also proved tough to manage under the GOP’s watch.
McCrory has said overhauling Medicaid is at the top of his legislative agenda and “may be the toughest battle” with lawmakers cool to earlier ideas to pay managed-care organizations a set fee and force them to work out how to deliver care within that budget.
The North Carolina Medical Society — which represents about 12,500 physicians and physician assistants in the state — the North Carolina Hospital Association, and other advocates for medical professionals and consumers have proposed a more conservative shifting of the risk for cost overruns.
The groups proposed expanding the more than 20 accountable care organizations already operating across North Carolina. The small networks of physicians or hospitals are paid by Medicaid for each procedure they perform. Organizations that meet savings and treatment goals get to keep a portion of the savings generated. If patient costs exceed standards, it must share losses with the state.
Problems in North Carolina’s Medicaid program have persisted for years and haven’t quit since McCrory took office last year and installed Wos as DHHS secretary.
A decision by the agency to delay recalculating Medicaid patient eligibility for three months could cost the state up to $2.8 million. Lawmakers have criticized the agency for not reporting those costs while they were developing the state budget last summer.
A group of North Carolina doctors filed a class-action lawsuit last month after flawed computer programs severely delayed payments they were due for treating Medicaid patients. The lawsuit alleges that managers at DHHS and its contractors were negligent in launching NCTracks, a nearly $500 million computer system intended to streamline the process of filing Medicaid claims and issuing payments.
The lawsuit alleged NCTracks’s software was riddled with thousands of errors that led to delays of weeks and sometimes months before doctors and hospitals received payment. That forced some medical practices to borrow money to meet payroll and others to stop treating Medicaid patients, the lawsuit said.
Earlier this month, DHHS announced it would spend up to $3.7 million on no-bid, personal service contracts with two firms that would advise the agency on running the Medicaid program. Internal McCrory administration memos released to The News & Observer of Raleigh describe understaffed and underskilled workers in the Medicaid division needing emergency help.
It’s a heart-stopping moment, but it happens regularly: A Medicaid provider, who never had any problems with the State of North Carolina, receives a letter from the North Carolina Attorney General’s Medicaid Investigations Division, or “MID”, informing her that she is the subject of an investigation of Medicaid billing practices. The MID’s core mission is to investigate and prosecute health care fraud committed by Medicaid providers. If you receive a letter from MID, it is an extremely serious matter and can instantly change everything you. You need to know what MID is, how you might become the subject of an investigation, and what to do if you are.
What is MID? MID is a subdivision of the North Carolina Department of Justice that is tasked primarily with investigating Medicaid fraud. MID has two main divisions, civil and criminal. The civil division investigates cases in which a provider may have made a false statement in order to obtain reimbursement payments. The civil division uses special powers granted by the North Carolina False Claims Act to investigate providers, determine if there is enough evidence to show a false statement resulting in reimbursement payments from Medicaid, and thereafter file a civil lawsuit to recover the money.
MID’s criminal division employs prosecutors whose job is to investigate, file criminal charges against, and convict providers who have intentionally and willfully obtained reimbursement payments under false pretenses. The MID website itself describes Medicaid fraud to include circumstances in which providers intentionally bill Medicaid for services not actually provided, use an improper procedure code to bill for a higher priced service when a lower priced service was provided, bill for non-covered services by describing the services as covered services, misrepresent a patient’s diagnosis and symptoms and bill Medicaid for a service that is medically unnecessary, or falsifies medical records. Any such acts could result in criminal prosecution.
As a responsible Medicaid provider, you might conclude that you would never have to worry about an MID investigation. After all, MID is tasked with investigating fraud, and the vast majority of providers honestly and lawfully provide services and submit reimbursement requests for those services. However, the new reality in Medicaid is that many honest providers can and do find themselves dealing with an MID investigation. A prime example, which happens frequently, is when DHHS finds a “credible allegation of fraud” regarding the provider. One would conclude that a “credible allegation of fraud” would be limited to hard evidence that a provider intentionally obtained reimbursements based on false information or some other bad act. However, the Medicaid regulations define a “credible allegation of fraud” to include the results of claims data mining. In other words, a “credible allegation of fraud” can be based simply on a computer analysis of a provider’s billings to Medicaid, and this has indeed been the basis of DHHS’ referral of cases to MID for investigation. For this reason, a number of honest providers have indeed found themselves the subject of an MID investigation, having to contend with the difficulty that such an investigation brings.
There are several key things that providers must know about an MID investigation. If you find yourself the subject of such an investigation, keep the following in mind:
• The first and most important: get a lawyer. The stakes in an MID investigation are extremely high, to include the potential for conviction of a crime. Proceeding without advice of counsel is very risky. Everyone who is subject of an investigation has substantial and important rights, but it takes an expert in this area of the law (and not necessarily me or my firm) to competently advise someone who is the subject of an MID investigation.
• Always remember that the State’s investigators and lawyers only work for the State. MID is staffed with competent, dedicated investigators and attorneys, and my dealings with them show that they are straightforward people. However, their job is to investigate fraud, and if you are the subject of an investigation, they have received information indicating that you may have committed fraud. You therefore should exercise caution when speaking with them, you are under no obligation to answer questions, and you certainly are under no such obligation without first hiring an attorney.
• Ensure that all your records are properly preserved. Part of MID’s investigation will certainly be a request to inspect and copy your records related to Medicaid billing, such as patient files, employee timesheets, records relating to claims submissions, and contracts with service providers. Any loss of such records will have to be explained, and if a loss occurs after a provider has received notice of an investigation, the provider could be accused of having destroyed records. It is therefore crucial that you preserve your records, both the ones on paper and the electronic data containing relevant information.
• Do not discuss the investigation or your Medicaid billing practices with anyone except your lawyer. Because you are the subject of an investigation that is based on information that may indicate you committed fraud, you must be careful about what you say. If you discuss matters with anyone but your lawyer, those persons could be compelled to testify about what you said, and it is not uncommon for someone to misquote, misunderstand, or otherwise misreport what someone has said. Speaking only with your lawyer is the safest course.
• Finally, be patient with the process. Being the subject of an MID investigation is stressful and frustrating, but MID currently is backlogged with a huge number of cases. This means that it will take time for the investigation to conclude. Expert counsel can help you through this process, but recognize that it will take a long time for it to conclude.
Dr. Robin Gary Cummings was named the new state Medicaid director today.
Dr. Cummings, a former cardiovascular surgeon, had been serving as the Acting State Health Director. He ceased pursuing surgery in 2004.
Interestingly, if you go the NC American Indian Health Board (found here), according to the website, Dr. Cummings is currently serving as the Medical Director for Community Care of the Sandhills. Obviously, Community Care of the Sandhills (CCS) is one of 14 non-profit organizations participating in the Community Care of NC (CCNC). CCS is covers Medicaid for Harnett, Hoke, Lee, Montgomery, Moore, Richmond, and Scotland counties.
However, when you go to CCS’ website, and click on “staff,” then, using the drop-down box, click on “leadership,” the Medical Director is Dr. William Stewart. So, obviously, Dr. Cummings has served in the past as the Medical Director for CCS.
After a bit more research, it appears that Dr. Cummings left CCS this past July 2013, when Sec. Wos appointed Dr. Cummings as the Acting State Health Director in lieu of Dr. Laura Gerald’s resignation. If you remember, Dr. Gerald’s resignation was unexpected and Sec. Wos gave no reason for Dr. Gerald’s resignation. Sec. Wos announced that Dr. Cummings would be taking Dr. Gerald’s place the very same day that Sec. Wos announced the resignation of Dr. Gerald.
So my question is this:
Why was Dr. Gerald replaced immediately by Dr. Cummings as the Acting State Health Director, while Carol Steckel resigned back in September 2013 and is being replaced by Dr. Cummings 4 1/2 months after Steckel’s resignation?
We haven’t had a State Medicaid Director (officially) for 4 1/2 months. Sandy Terrell stepped up as the temporary Medicaid Director. And we know Sec. Wos and team has been actively searching for new Medicaid Director.
In fact, the February 11, 2014, agenda (today) for the Joint Legislative Oversight Committee on Health and Human Services shows as its 11th topic, “Ideas to Address Staffing Concerns and Update on Medicaid Director Search.” Which tells me that there was little to no forewarning as to the appointment of Dr. Cummings.
It would be one thing if, after 4 1/2 months, Sec. Wos announced that the new State Medicaid Director was ____, someone from outside NC with excellent experience. She didn’t want to announce that _____ was coming to NC prematurely because it was confidential and ____ did not want the public to know prior to a final decision.
He has been working in NC Medicaid since 2004. He has served as the Acting State Health Director. Obviously, he was not hard to find. Obviously, Sec. Wos had contact with Dr. Cummings way back in September 2013. So why not appoint Dr. Cummings as the State Medicaid Director back in September 2013? Why wait 4 1/2 months? And announce his appointment the same day as the February 11, 2014, Joint Legislative Oversight Committee on Health and Human Services meeting? It just seems odd…
Maybe he refused the appointment back in September 2013. Maybe it took Sec. Wos 4 1/2 months to convince him to take the challenge. Because, come on, folks, Dr. Cummings has just elected to place himself in one of the hottest public seats in the state…and I mean scorching! Remember my blog: “Wanted: North Carolina Medical Director: Transparent and Open!”
Regardless the reason for the delay, it is encouraging that we have a new State Medicaid Director. I am sure Dr. Cummings is fully aware of the current disarray of the NC Medicaid system. So, even knowing the turmoil of our current Medicaid system and how daunting his task will be, Dr. Cummings still chose to accept the appointment to the State Medicaid Director position. And, for that, I say “Bravo!” And “Good luck!” And “We really hope you are successful!”
But, gracious, that seat will be hot!
“The oldest and strongest emotion of mankind is fear, and the oldest and strongest kind of fear is fear of the unknown” H.P. Lovecraft, “Supernatural Horror in Literature.” I completely agree. The unknown scares me way more than the known.
The unknown is what creates fear, right? For example, my husband is scared of heights. It is not the “heights” per se that scare him. He says that when he is high up, he gets an abnormal and understandably disturbing sense to throw himself off the ledge. He is scared, not of heights, but of his reaction to heights. Similarly, remember when I had an anxiety attack while I repelled (fell without any control) down the 22-story Wells Fargo building to raise money for the Special Olympics? To see my disastrous descend off of the Wells Fargo building, see my blog: ”The Future of Managed Care in Medicaid and the Fear of the Unknown.”
But unknowns to a Medicaid budget can be disastrous.
For those of you who live in North Carolina, you probably got some snow last Wednesday. I live in Raleigh, and we got about 3 inches. My law firm was actually closed Wednesday. While I have to say that it takes a lot of snow to close a law firm (I mean, come on, think of how much money we lost by having a non-productive day. Luckily, I work for a firm that cares more about the safety of its employees than the bottom line), I do live in the South. And snow scares us (actually, not snow per se (we aren’t actually scared of the little white flakes), but the fear of the unknown…what can happen because of snow?)
A few weeks ago snow was in the forecast (not on the ground) and my daughter’s school closed. Seriously, there was no snow, yet my daughter’s school was cancelled.. And Tuesday evening, the night before the Great Blizzard of 2014, the grocery store was slammed with people buying milk and bread (just in case we are stuck in our homes for weeks and could be on the brink of starvation due to the 3 inches of snow). My husband, being the good southerner that he is, keeps our water running all night to prevent freezing pipes. He also covers the vents outside with towels.
Needless to say our house was prepared for the snow.
But there are always unknowns. Especially when it comes to Medicaid budgets.
Our unknowns regarding the Great Blizzard of 2014? (1) No sled; and (2) Skinny, unpadded sleds = a bruised body.
We woke up Wednesday to 3 inches of snow and no sled. And our 8-year-old was aching to sled. How do we not have a sled? Hello…we are from the south. It snows here maybe every 3 years. So we run to Ace Hardware, because, according to my husband, it is family owned and run. Ace had 4 sleds left (obviously other southerners were quicker to think of sleds than we). Three of the sleds were very thin. Almost like a towel, but more stiff and made of plastic. One of the remaining sleds was thicker…a tad thicker than a boogey board with two yellow handles on each side. Of course, my daughter chose the thicker one, leaving me with the skinny, unpadded sled.
We drove to Shelley Lake at which there is a VERY steep, almost, straight-down hill. Seriously, I had to climb up on my knees because I couldn’t stand without sliding backward. And, due to the skinny, unpadded sled, as I shot down the hill, I felt every bump…every jolt…every drop….on my knees, elbows and belly. But it was fun, so we kept at it! My daughter yelled, “Best day ever!” (Which made me smile ear to ear).
My other unknown? Skinny, unpadded sleds equal a sore body with black and blue knees and elbows after 4-5 hours of sledding (and climbing up the steep hill). Again, chalk it up to me being a southerner. Literally, the last time I sledded was when Madison was 4…the Great Blizzard of 2010….and I didn’t have a skinny, unpadded sled then.
So here I am today, writing this, but unable to cross my legs or wear skirts above my knees or people would think that….hmmmm…..what would people think if they saw my swollen, bruised knees? That I jumped up and down on my knees? That something fell on my knees? That I fell on my knees? That someone beat me up…but only my knees? It is an odd thing to have bruised knees. They are very difficult to explain.
So too are Medicaid budgets. And Medicaid expenditures. Something always comes up. There is always grey (or black and blue). And they are very difficult to explain.
Think about it…we expect our legislature to come up with how much we will spend the future year based on the past. The General Assembly does not have a crystal ball (that I know of). Yet we expect the budget to be correct, and we expect to not exceed the budget. Otherwise we are over the budget. And bruised.
Last year, 2013, State Auditor Beth Wood stated that we had exceeded the State Medicaid budget by hundreds of millions of dollars for at least three years running. She estimated that going over the Medicaid budget by so much money cost the tax payers $1.2 billion. But how can you budget medical necessity for Medicaid recipients?
Well, NC is asking the feds for permission to decrease Medicaid spending by freezing Medicaid reimbursement rates. We have approximately 10 or more requests to the Center for Medicare and Medicaid Services (CMS) to freeze the Medicaid reimbursement rates for a range of Medicaid services.
How else do we try to decrease Medicaid spending? By hiring some managed care organizations (MCOs) to manage behavioral health and placing the risk of going over budget on the MCOs. Hello, people, rationally, how do you think that the risk-based model will be implemented by the MCOs. Surely the MCOs will be happy to have lots of providers in their catchment areas and happy to have lots of recipients so the MCO can pay out lots of money and receive little-to-no profit. And we live in Disneyland, and all the animals help us clean our homes!
The concept of MCOs managing behavioral health is not inherently bad. The WAY in which NC implemented MCOs and the pay-structure IS inherently bad. Even CMS agrees with me. See my blog: ”CMS Declares the Payment Structure for the MCOs Violates A-87…”So what Happens Now?”
So, besides freezing reimbursement rates and outsourcing risk, how else could we manage Medicaid costs?
DECREASE ADMINISTRATIVE COSTS.
Medically necessary Medicaid services should not be decreased. Reimbursement rates should be raised, not slashed. Medicaid providers should have the incentive to accept Medicaid, not the converse.
Decreasing administrative costs accomplishes decreasing Medicaid expenditures without harming the medically necessary Medicaid services to Medicaid recipients.
On the national level, between 2010 and 2011, total Medicaid expenditures increased by 6.4%. However, in 2012, the federal Health and Human Services Department (HHS) estimates that Medicaid expenditures will increase only 1.1%. HHS opines that the slower growth of Medicaid expenditures is because of States’ efforts to limit growth in light of budget constraints and the knowledge that the States will be liable for more Medicaid recipients (if such state expands) after the temporary federal matching reimbursement under the Affordable Care Act (ACA). In other words, we are spending less on Medicaid services.
Just to get perspective on how important Medicaid is to our overall budget and tax dollars, total Medicaid spending in 2011 was $432.4 billion with the feds paying $275.1 billion or 64% and the states paying $157.3 billion or 36%. That is a lot of tax dollars!
In 2011, nationally, administration costs increased from 2010 by 8.7%. This increase in the highest percentage increase in administrative costs since 2003.
And North Carolina’s administrative spending is abnormally high.
Back in October 2013, our State Auditor Beth Wood was quoted saying, “The administrative spending for the state’s Medicaid program is 38 percent higher than the average of nine states with similarly sized Medicaid programs,” Wood maintained. “While those states on average have administrative costs of 4.5 percent, the state of North Carolina spent over 6 percent of its total budget on administrative cost. In real dollars that means that the state is spending $180 million more than the average of our peer states.”
$180 million more than peer states spent on administrative costs…not services to Medicaid recipients…not reimbusements to providers accepting Medicaid….just for administrative costs.
On a national level, Medicaid administrative costs are only expected to increase.
Over the next 10 years, Medicaid expenditures are projected to increase at an average annual rate of 6.4% and to reach $795.0 billion by 2021. Average enrollment is projected to increase at an average annual rate of 3.4% over the next 10 years and to reach 77.9 million in 2021. See CMS report.
Because of the ACA , Medicaid expenditures are expected to increase by a total of $514 billion from 2012 through 2021. See id.
Nationally, Medicaid spending on program administration totaled $20.2 billion in 2011—$11.4 billion in Federal expenditures and $8.9 billion in State spending. See id.
Total Medicaid expenditures grew slightly faster in 2011 than in 2010, at a rate of 6.4 percent. Expenditures on benefits grew somewhat more slowly (6.3 percent) than in 2010, but administration expenditures increased at the fastest rate since 2003 (8.7 percent). See id.
Each year we have more citizens who qualify for Medicaid. Because of the ACA, we have the largest increase in the number of Medicaid recipients, quite possibly, ever in the history of Medicaid, except maybe during its inception.
Yet, the number of providers willing to accept Medicaid is not rising. “The average rate of acceptance among family physicians, dermatologists, cardiologists, orthopedic surgeons and obstetrician/gynecologists in all 15 markets surveyed was 45.7 percent last year, according to data gathered from nearly 1,400 medical offices last year.” “The 2014 survey showed a drop from 55.4 percent acceptance in 2009.” See 2014 Survey by Merritt Hawkins.
Here is the formula:
More Medicaid recipients + Higher administrative costs + Fewer providers accepting Medicaid = Catastrophe? Medicaid recipients not receiving the medically necessary services? The cost of administrating Medicaid takes away from medically necessary services to Medicaid recipients?
Black and blue Medicaid budgets?
Here in NC, we have opted to not expand Medicaid. However, not expanding does not equal less Medicaid recipients (obviously it means less than had we expanded), but regardless of expansion, the number of Medicaid recipients increase every year. Just like our general population grows.
While NC has not expanded, NC has not cut Medicaid administrative costs. Instead, we are freezing reimbursement rates and allowing the MCOs to cut mental health services and terminate providers. Yet, our Medicaid population continues to grow, despite not expanding Medicaid. More and more providers are opting to not accept Medicaid.
“North Carolina spent over 6 percent of its total budget on administrative cost. In real dollars that means that the state is spending $180 million more than the average of our peer states.” Beth Wood.
“We exceeded the State Medicaid budget by hundreds of millions of dollars for at least three years running.”
So what will become of our Medicaid state budget? Will our budget get black and blue from unexpected bumps in the road? Do we have a sled that is too skinny and unpadded?
The worst fear is the fear of the unknown.