04/30/07 — New Medicaid rates set

View Archive

New Medicaid rates set

By Matthew Whittle
Published in News on April 30, 2007 1:53 PM

After several weeks of discussion and controversy, the North Carolina Department of Health and Human Resources set new Medicaid reimbursement rates Thursday for community support providers in the mental health system.

Community support providers primarily offer consumers with mental illnesses and developmental disabilities the opportunity to learn life skills.

The rates for those services, which began the year at $60.96 per hour for individual child and adult services and $19.60 for group services, were reduced to interim rates of $40 and $12.80, respectively, on April 5.

However, as the department completed its service cost analysis last week, officials made the decision to bump the rates back up -- though still not to their original levels.

The new amounts are $51.28 for individual services and $16.48 for group services -- effective retroactive to April 5.

The number of billable hours also is being cut from 28 per week per client to 12. After 12 hours any service provided will be subject to automatic review.

The rates will reviewed again in 2008.

In a written statement, the department explained the rates were set with the help of 16 selected providers.

The changes were made in response to an increase in the use of community support services, which, by the end of March, had become the single largest Medicaid service. Payments to community support providers, the release said, were totaling more than those being made to hospitals, physicians and for prescription drugs.

Following that discovery, the department audited 167 providers across the state. They selected ones billing large amounts of community support services per consumer.

The department discovered that not only were some providers billing for services that should not have been covered, paraprofessional staff were delivering 98 percent of the services -- not the 75 percent the state had planned on.

Paraprofessionals are staff members without specialized training. Often they have high school diplomas or less.

However, Ken Jones, director of Eastpointe, the local mental health management agency for Wayne, Duplin, Lenoir and Sampson counties, said that he disagreed with the way the new rate was being implemented.

He explained that a large part of the problem was not necessarily the amount of the rate, but the way many providers were being reimbursed for services that shouldn't have qualified.

"They're authorizing what is submitted to them by the providers. That's my understanding," Jones said. "There needs to be more training for providers and for Value Option (the company handling the state's Medicaid billing) as to what community support was meant to be.

"It's a rehabilitative service. The intent is to give the client some skills they don't have. It's not an ongoing service. I think in many cases the plans are not being reviewed at an adequate level and the services are being overauthorized."

But, he continued, another part of the problem is that there are few long-term services available once the consumers build those first basic skills.

"People get stuck in these services and there's often nothing to refer them to," Jones said. "That's another reason they're being overbilled."

He also said that there should be a different rate for those services being provided by qualified professionals -- who cost the providers significantly more to hire -- and those being provided by paraprofessionals.

In Wayne County, he added, most providers offer a combination of the two, though the new rate will make it difficult for many to afford the qualified professionals.

In order to make up the cost, he explained that it is possible some providers will look for additional, more in-depth services as other rates were not changed.

But even that is another area of disagreement for Jones, who felt that if part of the system was going to be examined, everything should have been reviewed to determine what rates are really too high and which ones are too low -- in order to help build a better service capacity across the communities.

"This is not good for the providers who are trying to do a good job. This is going to affect many of our service providers. We need these services, but we're concerned about what they're going to do," he said. "This is a lot of change in a short amount of time. I just feel like this should have been transitioned better."