Friday, January 04, 2008

Endorsed Provider companies flounder under weight of post payment audits, penalties, payback: JUST WHO GET AUDITED?

Mr. Benton is on record this week as stating this as pertaining to the closure of public psychiatric hospitals, w/ Broughton having lost its ability to admit Medicare and Medicaid patients since, August, 2007, costing the NC taxpayers over one million dollars/ month in extra fees :'"We have to restore the public's faith in our facilities,"

Community Support Service (CSS) include emergency services and everything from counseling to skill building.

Ann Ackland, former board member for NC NAMI outlines how her daughter needs CSS but how it has failed: "“The plan sounds really good when you talk about being able to have people have services they need to stay in the community,” Ann Akland said. She added, however, “The execution is abysmal. It is failing.”

If you think CSS is failing now, just wait until more companies collapse under the weight of post payment reviews,audits, and paybacks---- commonly for inappropriate reasons.

Here is a case in point: the company with which I am affiliated offered 15 hrs/ week of CSS to a schizophrenic client, a Medicaid recipient. With this support, the client was able to obtain a GED and at least apply and go off to college----only to not be able to cope with campus life. The client is fortunate given the educated status of his parents and their relative wealth.

The CSS were begun in thet fall of 2006, prior to DHHS's demand that a Diagnostic Assessment be in place. Clearly in place in the medical records prior to the utilization of CSS was: my assessment; the psychiatrist's assessent; and, the psychiatric nurse practitioner's assessment.

As a person who had attempted to render therapy to the client I rather quickly noted that it was not very helpful and that what would be appropriate would be CSS in the form of someone younger, who could relate to the client in a more meaningful fashion and create a sense of ease , or more ease, in terms of interpersonal skills. CSS was the perfect remedy!

Almost one year after the beginning of CSS, SMC LME's Quality Management department, headed by Charles Barry, told the company with whom I am affiliated that there was no 'medical necessity' for the CSS and that the company needed to pay back $24,000 as associated w/ the CSS.

As associated with SMC LME Quality Management Department, a LPC (Licensed Professional Counselor : no diagnostic skills are part of the training for an LPC; I know: I used to be one) rendered the judgment and under the space soliciting the reviewer to recommend what services would be useful, she stated, "I don't know."

The penalty associated with post payment review paybacks is NOT part of the money to be paid back. Rather it is a penalty placed on the Endorsed Provider company which stays in place, eating their revenue, until all the money is paid back. Ten percent every month is extracted as a penalty on the money owed pertaining to the audit.

Endorsed Provider companies are given 15 days to come up with evidence that in fact the reviewer was mistaken. In the case of this client, the evidence is easily turned up given the electronic nature of the medical records and how well known the client was to the company and how many psychiatric contacts the client had throughout the system. .

The company with which I am affiliated is already reaping the 'benefits' of other Endorsed Provider companies crashing re: post payment reviews. The paybacks, legitimate or not, are sinking the companies.

You might say: well, but that's the penalty for not doing the work correctly----be it paperwork or what.

I'd ask you this: and so WHO are the companies that are being audited? The companies that spun out of the LME's e.g., retired employees or people who needed a job after the Community Mental Center morphed into an LME, are not being audited at the same rate.

So, you tell me: what is the purpose of the post payment reviews and the payback and penalties? I am currently turning up the information as re: specific companies and will be back w/ that information across various LME's.

Marsha V. Hammond, PhD


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