Monday, June 22, 2009

How to file a Medicaid complaint: Program Integrity information for people w/ disabilities & mental health concerns needing to formally complain

FROM: Marsha V. Hammond, PhD Licensed Psychologist, NC e mail: cell: 404 964 5338 fax: 828 254 2013

TO: Patrick Piggott, Supervisor Department of Medical Assistance, Medicaid Program Integrity 2501 Mail Service Center Raleigh NC 27699-2501

RE: inappropriate use of Psychosocial Rehabilitation Services, an Enhanced Benefits service for WNC Family Care Homes residents w/ Medicaid

June 21, 2009

Dear Patrick Piggott, Supervisor associated w/ NC DMA Program Integrity:

I filed a complaint today w/ ‘Cynthia’ at the DMA Program Integrity telephone number given to me by Mr. Donald Reuss, Director of Provider & Consumer Relations at Western Highlands Network LME in Asheville, NC. Here is the address for that LME: 356 Biltmore Avenue Asheville NC 28801
I outlined the following to Cynthia and the purpose of this letter is to underline the matter. I asked Cynthia when I could expect a response back from you. She stated: ‘it could be two days or two weeks.’ I will therefore be calling you by July 6, 2009, which is two weeks from now.

Here is the issue: my long-term client, -----------------------
Address: WNC Homes (a family care home based in Asheville, NC) --------- has been receiving an Enhanced Benefits Service from Medicaid whose proper name is ‘Community Support Services’ for the past year or two. Recently, the administration of WNC Homes, a Family Care Home, has demanded that the client attend a different Enhanced Benefits Services modality, specifically, Psychosocial Rehabilitation Services (PSR: the name of the company is ‘Health Care Solutions’).

My understanding is that Medicaid cannot pay for more than one Enhanced Benefits Services.

Besides, this point, ---------------- the client's Person Centered Plan does not include PSR; it includes CCS. This is a document which outlines all of ----------------- mental health services. I am the professional provider who signs off on this plan and assists in determining medical necessity. ----------------- has a head injury & cannot focus on verbal information presented in a PSR program. ------ should not be in a PSR program. It is inappropriate and an incorrect use of Medicaid monies----if Health Care Solutions is billing and being paid. Community Support Services is what is in order for -----------------.

Moreover, the Family Care Home has overstepped their boundaries in demanding that this client as well as other residents go to a PSR program when it is not in their Person Centered Plan, which, again, is the document which determines services.

Thank you for letting me know what is taking place re: my client. I will be calling you by July 6, 2009 if I do not hear from you by then.

Marsha V. Hammond, PhD


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