Tuesday, March 04, 2008

Easley wants to rein in 'abusive providers' and circumvent DUE PROCESS : DEVELOPING LAWSUIT AGAINST VALUE OPTIONS

The below was forwarded to a non-confidential host of providers and mental health advocates as pertaining to a solicitation for Medicaid Community Support Services denials by Doug Sea, Senior AttorneyLegal Services of Southern Piedmont 1431 Elizabeth AvenueCharlotte NC 28204Tel. (704) 971-2593Fax (704) 376-8627: dougs@lssp.org.

What does this have to do with Governor Easley's solicitation that 'abusive providers' should be reined in?

Those 'abusive providers' instituted Community Support Services (CSS) on the basis of guidelines that were in place when Hooker Odom was Secretary of DHHS and--- THEN---- DHHS decided they would change the criteria of CSS---after the $$ had been spent and after Value Options (VO) determined the services to be 'authorized.'

What criteria changed?

All of a sudden the Endorsed Provider companies were not supposed to have utilized 'high school graduates' who were 'taking clients shopping' or 'children to the swimming pool.' All of a sudden, under Hooker Odom, more than 15 hours/ CSS was NOT OK.

The leaky gauze that Hooker Odom attempted to plant on the rupture, 'after the fact', was an attempt to tackle the hemorhaging of CSS $$, when in fact NC was moving from almost dead last in terms of mental health $$ spent to somewhere in the middle-----and when the PURPOSE of CSS, as outlined in the continuing saga of CSS, and as per NC DHHS 'Attachment D: Service Definitions : Community Support- Adults (MH/SA) shall include the following: http://www.ncdhhs.gov/dma/bh/8A.pdf (see page 24)

These shall include the following, as clinically indicated:
• Identification of strengths that will aid the individual in his or her recovery, as well as barriers that impede the development of skills necessary for independent functioning in the community
• One-on-one interventions with the recipient, unless a group intervention is deemed more efficacious, to develop interpersonal, relational, and coping skills in the community, including adaptation to home, school, and work environments
• Therapeutic mentoring that directly increases the acquisition of skills needed to accomplish the goals of the Person Centered Plan
• Symptom monitoring
• Medication monitoring, with documented communication to prescribing physician(s)
• Self-management of symptoms
• Direct preventive and therapeutic interventions that will assist with skill building
• Assistance with skill enhancement or acquisition
• Relapse prevention and disease management strategies
• Psychoeducation and training of family, unpaid caregivers, and others who have a legitimate role in addressing the needs identified in the Person Centered Plan

It seems that 'we wanted an improvement of mental health services but not to THAT degree. ....

And 'learning to swim' or 'how to shop for your groceries' has NOTHING to do with tackling the matter of identifying 'barriers to skill development' or 'relapse prevention' as pertaining to isolated mentally ill people who stay in their houses all day and night because they have no transportation or live to far away (in rural western NC) to get anywhere.

My goodness: what do y ou think this is: 'hand holding?'
E mail solicitation from Doug Sea, attny, re: Due Process lawsuit against Value Options:

From: Doug Sea Sent: Friday, February 29, 2008 1:22 Subject: Due process lawsuit against Value OptionsImportance: High

So far the state has not responded to my demand to correct its illegal policy denying Maintenance of services. Other due process violations by value options also are continuing. I am now considering filing a class action lawsuit and need more information about persons who have been harmed to decide whether to pursue this further.

Please ask for client permission and then send me detailed examples of the following due process violations. I need fact summaries, copies of bad notices and other paperwork,and client identifying and contact information documenting these violations: names, contact info, summary of case, supporting documents, willingness to participate in lawsuit, provider name, case manager contact info, services at issue, diagnosis, hardship facts.

I particularly need details on cases where existing services were reduced or terminated by VO AND the family did NOT appeal OR is NOT getting continued services BECAUSE of due process violations by VO and DMA, such as those listed below. But I also want examples of these violations even if the case was appealed and client is still getting services. Here is my list of due process violations:

1. VO calls to case manager prior to issuing written denial to discourage appeal and to encouraging the family to withdraw the request for services
2. CAP-DD annual review “denial” notices from VO that fail to identify service being reduced or terminated,
3. VO notices mailed to family after the effective date of the termination or reduction of services
4. failure of VO notices to state what services VO is willing to approve in alternative to services being reduced or terminated
5. VO reduction of termination of service without showing any change in circumstances or medical improvement since same services previously approved
6. failure of VO and or informal hearing officer to consider evidence outside of the plan of care
7. failure to make med necessity decisions based on indiv facts of case but rather based on “guidelines” about how many hours are provided for this diagnosis or SNAP score
8. Failure of VO and informal hearing officer to consider facts/evidence between date of initial VO decision and date of informal hearing
9. failure of VO and or informal hearing officer to give appropriate weight to the opinion of treating clinician
10. Failure of VO to talk to treating clinicians before making decision
11. Failure to obtain more info or current info when needed before making decision
12. failure of VO to send written notice to the responsible person/guardian even where VO knows the recipient has a guardian
13. failure of VO to give reasons for its decision in the notice
14. failure of VO to provide copies of all records prior to informal hearing upon request

15. VO notices that fail to notify family of right to continued services (maintenance of service or MOS) pending appeal when existing services reduced or terminated, i.e. when request for reauthorization of existing service is denied
16. failure to provide MOS pending appeal because of change in providers OR family who wants to change providers but cant change providers because would lost MOS pending appeal
17. failure to provide MOS where interruption of less than 30 days between end of prior authorization and request to continue the service
18. failure to provide MOS until VO notice sent to family reducing or terminating service plus 11 days
19. Failure to provide MOS until informal hearing decision plus 11 days
20. VO sending a “denial” notice which does not specify right to MOS pending appeal when in fact VO is reducing or terminating existing services
21. failure of informal hearing officer to notify the family in the informal hearing decision of right to MOS if file formal appeal
22. failure to provide MOS pending formal appeal
23. failure to clearly identify in the notice the right to MOS and when it applies
24. failure to allow additional time to appeal and provide MOS until 11 days after proper notice sent to family

Thanks in advance for your prompt help with this. Let me know if questions. Please feel free to forward.

Douglas Sea
Senior Attorney
Legal Services of Southern Piedmont
1431 Elizabeth Avenue
Charlotte NC 28204
Tel. (704) 971-2593
Fax (704) 376-8627


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