State Legislature has passed a new law to protect due process.
You all likely have read the reports by RACmonitor regarding the debacle in New Mexico, wherein 15 behavioral healthcare companies, which comprised providers of 87.5 percent of such services in the state, had their Medicaid reimbursements suspended upon “credible allegations of fraud,” defined in 42 C.F.R. §455.23. Or you may have heard about the catastrophe from other news articles, or even seen the documentary, “The Shake-Up.”
In June 2013, Gov. Susana Martinez’s administration decided to freeze Medicaid funding to these 15 organizations after an audit allegedly found problems including overbilling and potential fraud, at which time the Attorney General was asked to investigate. The media did a great job covering the fallout. Public Consulting Group (PCG) conducted the audit. I am not a fan of auditors in general, and especially PCG, but in this case, PCG was not allowed to finish its audit, which uncovered no credible allegations of fraud. New Mexico – for whatever reason – ordered PCG to remove the statement that no credible allegations of fraud existed, and forwarded the resultant report to the Attorney General, stating that credible allegations of fraud existed.
I was actually the attorney hired to defend three of the 15 companies accused of fraud. I have not spoken out before, and I have to abide by attorney ethics issues. However, now that there has been a documentary, the amount of press in the media, and last week’s press release, I believe that I have the green light to discuss.
I became involved in the New Mexico behavioral healthcare suspension and termination administrative appeals back in July 2013. When the suspensions went into effect, the providers, the recipients, and the citizens of New Mexico were floored, as was the New Mexico Legislature. The Legislature requested that I fly to New Mexico to testify before it, along with a representative of PCG and the CEOs of the behavioral healthcare companies involved. I testified about my past experience with PCG, which included hundreds of audit appeals of PCG findings that were successfully overturned. My testimony was the beginning of a six-year relationship with these healthcare providers.
I can report now that most of the cases have been settled. Last week we settled the case for TeamBuilders, which was by far the biggest behavioral healthcare company in New Mexico. The Freedles, who owns the company, ran a tight ship. It was an impressive company. TeamBuilders’ documents were spot-on. In fact, when we appealed the alleged overpayment of over $12 million, the administrative law judge (ALJ) hired by the New Mexico Human Services Department (HSD), the single state agency charged with managing Medicaid for New Mexico, and paid by HSD, found that TeamBuilders owed only $896.35.
However, in New Mexico, as in many states, the ALJ only renders a recommended decision. The state agency has the last word, and in this case, HSD decided that the ALJ was wrong and that TeamBuilders owed the entire extrapolated amount. Of course, we appealed. An appeal of an administrative decision is called judicial review and goes to the state court. For judicial review, you cannot present any more evidence, so you have to rely on the transcript from the administrative appeal. That is why the administrative appeal is so important.
Concurrently, we had a lawsuit pending in state court for damages based on the government’s actions, which we claimed were illegal. HSD had suspended all these Medicaid reimbursements without due process, and we contended that by doing so, HSD breached its Medicaid contract with the providers.
On Aug. 21, 2019, we settled our appeal and our damages case. TeamBuilders got the money that had been suspended. We forewent our lawsuit for damages, but we got some pretty good promises in return from the current New Mexico administration. My crystal ball shows that TeamBuilders will become an integral part of serving the behavioral healthcare needs of New Mexico’s Medicaid recipients going forward – just like they were prior to June 2013.
In my opinion, my three clients from New Mexico were exemplary companies and provided medically necessary services to those most in need in the state. The settlement agreements include no admission of guilt on the parts of the healthcare providers or the government. It is my stance (and, remember, I have reviewed all the documents at issue) that there was never a question of guilt on behalf of my client providers. They deserved a “thank you,” not a referral. The debacle is finally over, and I wish the best for all the behavioral healthcare providers in New Mexico. The damages the providers endured are irreparable.
As a last comment, the Legislature was successful in passing a new regulation to protect the due process of healthcare providers in the future, in order to ensure that such a calamity never happens again.
Programming Note:
Listen to Knicole Emanuel every Monday on Monitor Mondays, 10-10:30 a.m. EST.
Literature is ripe with classic phrases that seem timelessly apropos. For example, take the partial federal government shutdown. For days, the phrase repeated in the
The Medicare Advantage (MA) program has grown significantly over the past two decades, becoming a popular alternative to traditional Medicare fee-for-service (FFS). As of 2023,
Please log in to your account to comment on this article.
Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.
Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.
Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks. Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.
Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.
During this RACmonitor webcast Dr. Ronald Hirsch spotlights the areas of the OIG’s Work Plan and the findings of their most recent audits that impact utilization review, case management, and audit staff. He also provides his common-sense interpretation of the prevailing regulations related to those target issues. You’ll walk away better equipped with strategies to put in place immediately to reduce your risk of paybacks, increased scrutiny, and criminal penalties.
Copyright © 2024 RACmonitor. Powered by MedLearn Media.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
