10/01/07 — Providers identified for errors in service

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Providers identified for errors in service

By Matthew Whittle
Published in News on October 1, 2007 1:46 PM

The mental health private provider network in Wayne County is in the process of being shaken up, but Eastpointe Director Ken Jones said he is not too worried about any potential adverse effects on the client base.

Currently, the network is undergoing two different reviews. One -- a postpayment review -- was scheduled to be completed by the end of the month. The other -- an endorsement review -- had its deadline extended from Sept. 20 until Nov. 30.

The first, Jones explained, was requested by the state legislature after Medicaid bills for community support services came in much higher than expected, and a resulting audit found providers being paid for services that should not have been approved under the current guidelines.

But, he continued, while that spring audit resulted in a number of paybacks, nobody is sure yet what effect this most recent round of reviews will have.

Across the state, of the 11,298 service records reviewed as of Sept. 11, 4,074 were found to have not been clinically necessary. And of the 7,224 that were found to be clinically necessary, only 1,181 were for the appropriate duration and intensity.

"Across the state, the reviews did not go so well," Jones said. "But our reviews in the Eastpointe cachement area were a little better than average."

At Eastpointe, which covers Wayne, Duplin, Sampson and Lenoir counties, review teams have just about completed their critique of all 659 records designated by the state for examination.

Of those, 198 were found to be not critically necessary, while of the 450 that were, only 207 were found to be of inappropriate duration and intensity.

The records come from a five-month period and do not include every case handled by the private community support providers. They are focused mainly on those cases in which clients received more than 12 hours of treatment a week.

"Most of our providers were involved in this review, but not all of them," Jones said.

And in almost every case where there were problems, he explained that he believed they were not because of fraud, but rather a misunderstanding of what was acceptable. He also noted that each of the cases had supposedly been reviewed by Value Option, the company hired by the state to handle Medicaid payments.

"I don't know who to blame," Jones said. "I think the blame could go many places, but (Medicaid payments) don't appear to have been scrutinized like the process we (the LMEs) go through for indigent clients."

Had Medicaid payment reviews been left in the hands of the LMEs, he continued, he believes there might not have been so many problems.

"Having one statewide vendor, I do believe they're less likely to pick up on trends that we'd see on the local level because we know our providers," he said.

He also thinks that a lax endorsement process and a lack of direction from the state might have played into the problems.

"The endorsement rules were such that anybody could come in and practice, as long as they met the rules, which was not that hard," he said. "On top of that, there also was not a good understanding by many of the providers of how to implement this service."

But he is hopeful that by going through this process, the state will be able to refine those service definitions -- without penalizing the providers too harshly.

"If you've got that many with problems, there had to be some misunderstanding as to how this definition should be implemented," he said. "Most of them provided the services in good conscience and thought they were implementing it the right way."

The second review process concerns the community support providers' actual endorsement status.

And, Jones said, with the exception of a handful of providers who voluntarily got out of the business, every provider in the Eastpointe cachement area has been fully endorsed.

That does not mean that there aren't issues still being corrected -- almost every provider also received a corrective action plan -- but, he continued, no endorsements have been pulled as of yet. Providers under corrective action will have the opportunity to work through three plans before they risk losing their endorsements.

"It's still a process," Jones said.

And while he does expect more of the providers to eventually lose their endorsements, he also thinks the network is going to become stronger for it.

"We're not just letting them get by and there have been some that realized it was best they no longer be part of the network," he said. "But I don't think we're going to lose too many. I think Eastpointe has enough quality community support providers that if we lose some, we'll be able to transition clients."